Provider Demographics
NPI:1043228919
Name:PROVIDENTIAL WESTERN MEDICAL
Entity Type:Organization
Organization Name:PROVIDENTIAL WESTERN MEDICAL
Other - Org Name:WESTERN MEDICAL
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DIRECTOR OF INFORMATION AND FINANCE
Authorized Official - Prefix:MRS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:DANIELLE
Authorized Official - Last Name:SWINBOURNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-744-2770
Mailing Address - Street 1:2202 E UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85034-6840
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2202 E UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85034-6840
Practice Address - Country:US
Practice Address - Phone:602-257-9347
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies