=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801490461
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ASHLEY CLYDE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/24/2020
-----------------------------------------------------
Last Update Date | 11/24/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2432 W PEORIA AVE STE 1200
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85029-4736
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-715-8045
-----------------------------------------------------
Fax | 602-441-4673
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2432 W PEORIA AVE STE 1200
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85029-4736
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-715-8045
-----------------------------------------------------
Fax | 602-441-4673
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JODI L LINDSTROM
-----------------------------------------------------
Credential | ATP
-----------------------------------------------------
Telephone | 623-826-1207
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QX0100X
-----------------------------------------------------
Taxonomy Name | Occupational Medicine Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------