=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659601326
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DAUGHTERS OF THUNDER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/02/2010
-----------------------------------------------------
Last Update Date | 01/02/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4609 S MILL AVE
-----------------------------------------------------
City | TEMPE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85282-6720
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-486-7521
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 23714 4609 S MILL
-----------------------------------------------------
City | TEMPE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85285-3714
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-486-7521
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MISS KIMBERLY BLANTON-PIERCE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 602-486-7521
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number | 527632908
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 527632908
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 305S00000X
-----------------------------------------------------
Taxonomy Name | Point of Service
-----------------------------------------------------
License Number | 527632908
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 343900000X
-----------------------------------------------------
Taxonomy Name | Non-emergency Medical Transport (VAN)
-----------------------------------------------------
License Number | 527632908
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------