Healthcare Provider Details

I. General information

NPI: 1063230944
Provider Name (Legal Business Name): NEUSHAPE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2024
Last Update Date: 09/30/2024
Certification Date: 09/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9700 N 91ST ST STE A115
SCOTTSDALE AZ
85258-5036
US

IV. Provider business mailing address

1786 W HAWK WAY
CHANDLER AZ
85286-8016
US

V. Phone/Fax

Practice location:
  • Phone: 480-360-1222
  • Fax: 602-938-5135
Mailing address:
  • Phone: 480-360-1222
  • Fax: 602-938-5135

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: NICHOLAS DAVID HARREL
Title or Position: PRESIDENT
Credential: MD
Phone: 602-432-6962