Healthcare Provider Details

I. General information

NPI: 1396175287
Provider Name (Legal Business Name): PASSPORT HEALTH OHIO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2013
Last Update Date: 11/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38 BOLAND CT
GREENVILLE SC
29615
US

IV. Provider business mailing address

6710 E CAMELBACK RD
SCOTTSDALE AZ
85251
US

V. Phone/Fax

Practice location:
  • Phone: 888-909-6551
  • Fax: 480-383-6567
Mailing address:
  • Phone: 888-909-6551
  • Fax: 480-383-6567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateSC

VIII. Authorized Official

Name: VICKI SOWARDS
Title or Position: CLINICAL RN SUPERVIS
Credential:
Phone: 888-909-6551