=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104230853
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEART OF HEALING AZ
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/19/2014
-----------------------------------------------------
Last Update Date | 06/19/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4401 N 16TH ST
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85016-5302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-413-0424
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4401 N 16TH ST
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85016-5302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-413-0424
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER, PRACTITIONER
-----------------------------------------------------
Name | AEIMEE GLORIA DIAZ
-----------------------------------------------------
Credential | L. AC.
-----------------------------------------------------
Telephone | 602-413-0424
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 302R00000X
-----------------------------------------------------
Taxonomy Name | Health Maintenance Organization
-----------------------------------------------------
License Number | 0764
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 305R00000X
-----------------------------------------------------
Taxonomy Name | Preferred Provider Organization
-----------------------------------------------------
License Number | 0764
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------