=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366059982
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HONORHEALTH-FASTMED AMBULATORY HOLDINGS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/28/2020
-----------------------------------------------------
Last Update Date | 09/28/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5259 W INDIAN SCHOOL RD STE 100
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85031-2651
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-888-5101
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2500 W UTOPIA RD
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85027-4171
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-587-5314
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EVP/CPE
-----------------------------------------------------
Name | JOHN NEIL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 480-587-5123
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QU0200X
-----------------------------------------------------
Taxonomy Name | Urgent Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------