Basic Information
| Provider Information | |||||||||
| NPI: | 1386070076 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PWW HEALTH CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1121 E MISSOURI AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850142713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6028895833 | ||||||||
| FaxNumber: | 6028895834 | ||||||||
| Practice Location | |||||||||
| Address1: | 3202 E GREENWAY RD | ||||||||
| Address2: | SUITE 1619 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850324548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024822282 | ||||||||
| FaxNumber: | 6024822909 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2013 | ||||||||
| LastUpdateDate: | 05/22/2015 | ||||||||
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| AuthorizedOfficialLastName: | WAYCHOFF | ||||||||
| AuthorizedOfficialFirstName: | PIERCE | ||||||||
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| AuthorizedOfficialTitleorPosition: | SOLE MBR | ||||||||
| AuthorizedOfficialTelephone: | 6024822282 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Case Manager/Care Coordinator | 363LF0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.