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	:	1992592349
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	:	3711 JOHN F. KENNEDY PARKWAY
Second Line	:	SUITE 330
City	:	FORT COLLINS
State	:	CO
Zip	:	80525
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	:	04/21/2025
Last Update Date	:	04/21/2025

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