=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316800733
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PASSPORT HEALTH HOLDINGS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/03/2025
-----------------------------------------------------
Last Update Date | 12/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1011 NORTH BROOKSIDE RD
-----------------------------------------------------
City | ALLENTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-358-8648
-----------------------------------------------------
Fax | 877-877-6875
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4343 EAST OUTLIER BLVD. SUITE 100W
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85008-6507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-358-8648
-----------------------------------------------------
Fax | 877-877-6875
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL BILLING SPECIALIST
-----------------------------------------------------
Name | JUANA SLACK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 480-646-9086
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 172V00000X
-----------------------------------------------------
Taxonomy Name | Community Health Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------