=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457978215
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VALLEY DIRECT PRIMARY CARE, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/28/2020
-----------------------------------------------------
Last Update Date | 08/06/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9240 W UNION HILLS DR STE 100
-----------------------------------------------------
City | PEORIA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85382-8213
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-562-0130
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13970 W WOODBRIDGE AVE
-----------------------------------------------------
City | GOODYEAR
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85395-1485
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-562-0130
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | TARUN BASSI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 623-562-0130
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------