MEDICARE: PASSPORT HEALTH HOLDINGS, 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	261Q00000X	Clinic/Center		SC

General Provider Information

NPI Number	:	1619394335
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PASSPORT HEALTH HOLDINGS, LLC

Provider Business Mailing Address
First Line	:	668 N 44TH ST
Second Line	:	SUITE 100W
City	:	PHOENIX
State	:	AZ
Zip	:	85008-6507
Country	:	US
Telephone Number	:	877-358-8648
Fax Number	:	877-877-6875

Provider Business Practice Location Address
First Line	:	37 VILLA ROAD
Second Line	:	SUITE 301
City	:	GREENVILLE
State	:	SC
Zip	:	29615-3038
Country	:	US
Telephone Number	:	877-358-8648
Fax Number	:	877-877-6875

Authorized Official
Title or Position	:	CHIEF OPERATING OFFICER
Name	:	MR. PAUL FISHBURN
Credential	:
Telephone Number	:	480-646-9020

Provider Enumeration Date	:	03/19/2014
Last Update Date	:	04/01/2022

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