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General NPI Number Information
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NPI Number | 1295009561
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Entity Type | Organization
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Legal Business Name | HEARTFIT FOR DUTY LLC
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Dates
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Enumeration Date | 03/02/2012
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Last Update Date | 04/02/2013
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Provider Practice Location Address
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Address Line | 633 E RAY RD SUITE 101
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City | GILBERT
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State | AZ
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Zip | 85296-4200
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Country | US
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Telephone | 480-999-7911
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Fax | 480-499-5829
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Provider Business Mailing Address
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Address Line | 4192 E PALM BEACH DR
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City | CHANDLER
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State | AZ
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Zip | 85249-7398
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Country | US
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Telephone | 602-402-5090
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Fax |
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Authorized Official
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Title or Position | DIRECTOR OF OPERATIONS
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Name | MRS. KEPRA L JACK
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Credential | RN
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Telephone | 602-402-5090
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LA2200X
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Taxonomy Name | Adult Health Nurse Practitioner
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License Number | AP3059
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License Number State | AZ
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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