=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447008750
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | POUYAN MOABED OWNER
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/10/2024
-----------------------------------------------------
Last Update Date | 05/10/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2942 N 24TH ST
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85016-7844
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-662-1333
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2942 N 24TH ST STE 114-595
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85016-7844
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-662-1333
-----------------------------------------------------
Fax | 602-281-4960
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 374U00000X
-----------------------------------------------------
Taxonomy Name | Home Health Aide
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------