Healthcare Provider Details

I. General information

NPI: 1609206564
Provider Name (Legal Business Name): PASSPORT HEALTH HOLDINGS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2013
Last Update Date: 07/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2318-B SUNSET BLVD
WEST COLUMBIA SC
29169-4716
US

IV. Provider business mailing address

8324 E HARTFORD DR SUITE 200
SCOTTSDALE AZ
85255-5466
US

V. Phone/Fax

Practice location:
  • Phone: 877-358-8648
  • Fax: 877-877-6875
Mailing address:
  • Phone: 877-358-8648
  • Fax: 877-877-6875

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateSC

VIII. Authorized Official

Name: MR. DOUG SHACKELL
Title or Position: DIRECTOR OF FINANCE
Credential:
Phone: 480-646-9024