Basic Information
Provider Information | |||||||||
NPI: | 1346691136 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | INCREDIBLE HEALTH LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 13385 | ||||||||
Address2: |   | ||||||||
City: | SCOTTSDALE | ||||||||
State: | AZ | ||||||||
PostalCode: | 852673385 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4806099300 | ||||||||
FaxNumber: | 4806099350 | ||||||||
Practice Location | |||||||||
Address1: | 10595 N TATUM BLVD | ||||||||
Address2: | SUITE E-141 | ||||||||
City: | PARADISE VALLEY | ||||||||
State: | AZ | ||||||||
PostalCode: | 852531072 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4804183678 | ||||||||
FaxNumber: | 4809994447 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/23/2016 | ||||||||
LastUpdateDate: | 06/23/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HARRISON | ||||||||
AuthorizedOfficialFirstName: | TONI | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 4804183678 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174H00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Health Educator |   | 207L00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |   | 208D00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |   |
No ID Information.