Healthcare Provider Details

I. General information

NPI: 1831895861
Provider Name (Legal Business Name): VALLEY JOINT RESTORATION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2023
Last Update Date: 05/24/2023
Certification Date: 05/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5111 N SCOTTSDALE RD STE 106
SCOTTSDALE AZ
85250-7076
US

IV. Provider business mailing address

5111 N SCOTTSDALE RD STE 106
SCOTTSDALE AZ
85250-7076
US

V. Phone/Fax

Practice location:
  • Phone: 480-687-9096
  • Fax:
Mailing address:
  • Phone: 480-231-9569
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: LEEANN JENNINGS
Title or Position: CLINIC OWNER
Credential:
Phone: 480-231-9569