Healthcare Provider Details

I. General information

NPI: 1417250671
Provider Name (Legal Business Name): PHOENIX VA HEALTHCARE SYSTEMS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2010
Last Update Date: 12/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9258 E 27TH ST
TUCSON AZ
85710-7405
US

IV. Provider business mailing address

9258 E 27TH ST
TUCSON AZ
85710-7405
US

V. Phone/Fax

Practice location:
  • Phone: 520-403-2757
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code286500000X
TaxonomyMilitary Hospital
License Number1035321
License Number StateAZ

VIII. Authorized Official

Name: MS. NICOLE LESCHAK
Title or Position: REGISTERED DIETITAN
Credential:
Phone: 602-277-5551