=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609300854
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DENOVA COLLABORATIVE HEALTH, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/14/2017
-----------------------------------------------------
Last Update Date | 09/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3330 N 2ND ST STE 601
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85012-2395
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-230-7373
-----------------------------------------------------
Fax | 602-682-7455
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3101 N CENTRAL AVE STE 500
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85012-2639
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-230-7373
-----------------------------------------------------
Fax | 602-682-7455
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. GRAHAM JOHNSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 602-230-7373
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------