Healthcare Provider Details

I. General information

NPI: 1639791890
Provider Name (Legal Business Name): WESTERN CANAL HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2020
Last Update Date: 07/20/2022
Certification Date: 07/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6100 S RURAL RD
TEMPE AZ
85283-2904
US

IV. Provider business mailing address

6100 S RURAL RD
TEMPE AZ
85283-2904
US

V. Phone/Fax

Practice location:
  • Phone: 480-831-8660
  • Fax:
Mailing address:
  • Phone: 480-831-8660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: SOON BURNAM
Title or Position: TREASURER
Credential:
Phone: 949-540-1249