Healthcare Provider Details

I. General information

NPI: 1821091158
Provider Name (Legal Business Name): ARIZONA MEDSOURCE HOLDINGS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2005
Last Update Date: 09/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8260 E RAINTREE DR STE 202
SCOTTSDALE AZ
85260-2516
US

IV. Provider business mailing address

14747 N NORTHSIGHT BLVD STE 111 PMB 328
SSOTTSDALE AZ
85260
US

V. Phone/Fax

Practice location:
  • Phone: 480-292-8496
  • Fax: 866-561-8331
Mailing address:
  • Phone: 480-292-8496
  • Fax: 866-561-8331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number07502892T
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number
License Number State

VIII. Authorized Official

Name: JACKIE KEENE
Title or Position: OWNER
Credential:
Phone: 480-292-8496