=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144797374
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRESTIGE PRIMARY CARE, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/25/2018
-----------------------------------------------------
Last Update Date | 04/05/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21321 E OCOTILLO RD STE 102
-----------------------------------------------------
City | QUEEN CREEK
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85142-5993
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-815-7074
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1009
-----------------------------------------------------
City | QUEEN CREEK
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85142-1821
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-815-7074
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | CANDEE J EISENHART
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 480-815-7074
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------