Basic Information
Provider Information | |||||||||
NPI: | 1962961474 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | AKDHC, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6622 N 91ST AVE STE 220 | ||||||||
Address2: |   | ||||||||
City: | GLENDALE | ||||||||
State: | AZ | ||||||||
PostalCode: | 853052569 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6027596883 | ||||||||
FaxNumber: | 6022243358 | ||||||||
Practice Location | |||||||||
Address1: | 2201 N VICKEY ST STE 110 | ||||||||
Address2: |   | ||||||||
City: | FLAGSTAFF | ||||||||
State: | AZ | ||||||||
PostalCode: | 860046106 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9282139460 | ||||||||
FaxNumber: | 9282139465 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/14/2019 | ||||||||
LastUpdateDate: | 03/14/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ESCOBEDO | ||||||||
AuthorizedOfficialFirstName: | ADONIS | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
AuthorizedOfficialTelephone: | 6027596883 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MISS | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
ID | Type | State | Issuer | Description | 244929 | 05 | AZ |   | MEDICAID |