Healthcare Provider Details

I. General information

NPI: 1649780198
Provider Name (Legal Business Name): SKYSONG MEDICAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2017
Last Update Date: 01/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1375 N SCOTTSDALE RD STE 180
SCOTTSDALE AZ
85257-3428
US

IV. Provider business mailing address

1375 N SCOTTSDALE RD STE 180
SCOTTSDALE AZ
85257-3428
US

V. Phone/Fax

Practice location:
  • Phone: 480-874-9800
  • Fax: 480-874-9804
Mailing address:
  • Phone: 480-874-9800
  • Fax: 480-874-9804

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. CHALLEN WAYCHOFF III
Title or Position: COO/MANAGER
Credential:
Phone: 480-634-6400