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	172V00000X	Community Health Worker

General Provider Information

NPI Number	:	1972462026
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PASSPORT HEALTH HOLDINGS, LLC

Provider Business Mailing Address
First Line	:	4343 EAST OUTLIER BLVD.
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	:	14416 JEFFERSON DAVIS HWY
Second Line	:	SUITE 15
City	:	WOODBRIDGE
State	:	VA
Zip	:	22191
Country	:	US
Telephone Number	:	877-358-8648
Fax Number	:	877-877-6875

Authorized Official
Title or Position	:	MEDICAL BILLING SPECIALIST
Name	:	JUANA SLACK
Credential	:
Telephone Number	:	480-646-9086

Provider Enumeration Date	:	01/15/2026
Last Update Date	:	01/15/2026

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