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General NPI Number Information
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NPI Number | 1053595751
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Entity Type | Organization
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Legal Business Name | PROVISTA HEALTH, LLC
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Dates
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Enumeration Date | 12/18/2007
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Last Update Date | 09/13/2019
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Provider Practice Location Address
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Address Line | 17301 N PERIMETER DR SUITE 100
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City | SCOTTSDALE
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State | AZ
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Zip | 85255-5468
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Country | US
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Telephone | 602-224-5500
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Fax |
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Provider Business Mailing Address
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Address Line | 17301 N PERIMETER DR SUITE 100
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City | SCOTTSDALE
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State | AZ
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Zip | 85255-5468
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Country | US
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Telephone | 602-224-5500
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | TARUN JOLLY
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Credential |
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Telephone | 504-236-4030
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number | 03D1063366
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License Number State | AZ
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