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General NPI Number Information
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NPI Number | 1598194797
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Entity Type | Organization
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Legal Business Name | PASSPORT HEALTH HOLDINGS LLC
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Dates
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Enumeration Date | 11/07/2013
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Last Update Date | 07/11/2016
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Provider Practice Location Address
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Address Line | 10730 PACIFIC ST STE 221
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City | OMAHA
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State | NE
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Zip | 68114-4794
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Country | US
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Telephone | 877-358-8648
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Fax | 877-877-6872
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Provider Business Mailing Address
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Address Line | 8324 E HARTFORD DR STE 200
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City | SCOTTSDALE
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State | AZ
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Zip | 85255-5466
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Country | US
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Telephone | 877-358-8648
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Fax | 877-877-6875
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Authorized Official
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Title or Position | DIRECTOR OF FINANCE
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Name | MR. DOUG SHACKELL
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Credential |
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Telephone | 480-646-9024
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State | NE
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Taxonomy #2
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Taxonomy Code | 2083P0901X
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Taxonomy Name | Public Health & General Preventive Medicine Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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