Basic Information
| Provider Information | |||||||||
| NPI: | 1508272188 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ONESOURCE SENIOR HEALTHCARE PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14050 N 83RD AVE STE 290 | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853815650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8884954489 | ||||||||
| FaxNumber: | 6028658090 | ||||||||
| Practice Location | |||||||||
| Address1: | 16427 N SCOTTSDALE RD STE 410 | ||||||||
| Address2: | |||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852547102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8884954489 | ||||||||
| FaxNumber: | 6023250169 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2014 | ||||||||
| LastUpdateDate: | 06/17/2019 | ||||||||
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| AuthorizedOfficialLastName: | SHABA | ||||||||
| AuthorizedOfficialFirstName: | PHDRA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8884954489 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | OD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 231H00000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist | 213E00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 944102 | 05 | AZ | MEDICAID |