MEDICARE: PROMEDISCH, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	AP4802	AZ

General Provider Information

NPI Number	:	1144752759
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROMEDISCH, LLC

Provider Business Mailing Address
First Line	:	39506 N DAISY MOUNTAIN DR
Second Line	:	SUITE 122-169
City	:	ANTHEM
State	:	AZ
Zip	:	85086-1663
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2525 W CAREFREE HWY STE 118
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85085-9302
Country	:	US
Telephone Number	:	623-748-9106
Fax Number	:	602-429-8579

Authorized Official
Title or Position	:	NP
Name	:	LAURA MAGOFFIE
Credential	:
Telephone Number	:	623-748-9106

Provider Enumeration Date	:	04/02/2017
Last Update Date	:	01/25/2018

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Directions to “PROMEDISCH, LLC ” Practice Location

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