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General NPI Number Information
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NPI Number | 1285242560
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Entity Type | Organization
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Legal Business Name | GROWING SPACE LLC
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Dates
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Enumeration Date | 07/22/2020
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Last Update Date | 07/22/2020
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Provider Practice Location Address
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Address Line | 3940 S 79TH DR
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City | PHOENIX
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State | AZ
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Zip | 85043-1694
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Country | US
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Telephone | 480-347-8265
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Fax |
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Provider Business Mailing Address
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Address Line | 3940 S 79TH DR
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City | PHOENIX
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State | AZ
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Zip | 85043-1694
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OCCUPATIONAL THERAPIST
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Name | JOURNE DOMEK
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Credential | OTL
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Telephone | 480-347-8265
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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