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General NPI Number Information
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NPI Number | 1184346405
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Entity Type | Organization
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Legal Business Name | PROUDLY ARIZONA LLC
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Dates
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Enumeration Date | 09/13/2022
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Last Update Date | 09/13/2022
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Provider Practice Location Address
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Address Line | 1717 W NORTHERN AVE STE 106
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City | PHOENIX
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State | AZ
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Zip | 85021-5400
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Country | US
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Telephone | 323-378-8797
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Fax |
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Provider Business Mailing Address
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Address Line | 4816 W BETHANY HOME RD APT 90
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City | GLENDALE
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State | AZ
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Zip | 85301-5233
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Country | US
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Telephone | 323-378-8797
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Fax |
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Authorized Official
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Title or Position | OWNER/MANAGER
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Name | ESRA A KHALEEL
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Credential | MS
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Telephone | 323-378-8797
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 342000000X
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Taxonomy Name | Transportation Network Company
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 343900000X
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Taxonomy Name | Non-emergency Medical Transport (VAN)
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License Number |
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License Number State |
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