Healthcare Provider Details

I. General information

NPI: 1336304229
Provider Name (Legal Business Name): AVESIS THIRD PARTY ADMINISTRATORS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2008
Last Update Date: 10/04/2023
Certification Date: 10/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1275 W WASHINGTON ST STE 102
TEMPE AZ
85288-1859
US

IV. Provider business mailing address

1275 W WASHINGTON ST STE 102
TEMPE AZ
85288-1859
US

V. Phone/Fax

Practice location:
  • Phone: 800-643-1132
  • Fax:
Mailing address:
  • Phone: 800-502-0258
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER L MOORE
Title or Position: REGULATORY LICENSE MANAGER
Credential:
Phone: 207-356-4244