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General NPI Number Information
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NPI Number | 1922767607
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Entity Type | Organization
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Legal Business Name | ISLAND DREAM DEVLOPMENT LLC
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Dates
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Enumeration Date | 12/10/2021
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Last Update Date | 12/10/2021
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Provider Practice Location Address
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Address Line | 10339 N SCOTTSDALE RD
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City | SCOTTSDALE
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State | AZ
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Zip | 85253-1426
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Country | US
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Telephone | 515-338-0095
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Fax |
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Provider Business Mailing Address
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Address Line | 15160 N HAYDEN RD
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City | SCOTTSDALE
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State | AZ
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Zip | 85260-2587
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. FARHOUD KHOSRAVI
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Credential | DO
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Telephone | 515-338-0095
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number |
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License Number State |
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