Healthcare Provider Details

I. General information

NPI: 1134803265
Provider Name (Legal Business Name): SAB EDWARDS CNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2023
Last Update Date: 02/28/2024
Certification Date: 02/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15639 N VERDE ST
SURPRISE AZ
85378-4168
US

IV. Provider business mailing address

4811 N 96TH LN
PHOENIX AZ
85037-1063
US

V. Phone/Fax

Practice location:
  • Phone: 623-248-4100
  • Fax:
Mailing address:
  • Phone: 623-248-4100
  • Fax: 623-248-1534

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License NumberSLH10671
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License NumberSLH10671
License Number StateAZ
# 4
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberSLH10671
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: