Provider Demographics
NPI:1013646678
Name:ETERNITY SERVICES LLC
Entity Type:Organization
Organization Name:ETERNITY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:DERRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:MONTGOMERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-621-5126
Mailing Address - Street 1:2925 W MYRTLE AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85051-7538
Mailing Address - Country:US
Mailing Address - Phone:602-621-5126
Mailing Address - Fax:
Practice Address - Street 1:2200 W BETHANY HOME RD STE 1
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-1937
Practice Address - Country:US
Practice Address - Phone:602-601-4104
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-08
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)