Basic Information
| Provider Information | |||||||||
| NPI: | 1720502073 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AKDHC, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3333 E CAMELBACK RD STE 180 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850182396 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029970484 | ||||||||
| FaxNumber: | 6022243315 | ||||||||
| Practice Location | |||||||||
| Address1: | 4475 S I 19 FRONTAGE RD STE 101 | ||||||||
| Address2: | |||||||||
| City: | GREEN VALLEY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856145884 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5206223569 | ||||||||
| FaxNumber: | 5206237257 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2017 | ||||||||
| LastUpdateDate: | 07/28/2017 | ||||||||
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| AuthorizedOfficialLastName: | ESCOBEDO | ||||||||
| AuthorizedOfficialFirstName: | ADONIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6029970484 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 244929 | 05 | AZ | MEDICAID |