Provider Demographics
NPI:1073131561
Name:PONDEROSA HEART HOUSE CALL
Entity Type:Organization
Organization Name:PONDEROSA HEART HOUSE CALL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATIONS OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:STARLA
Authorized Official - Middle Name:LUCILLE
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:480-365-8454
Mailing Address - Street 1:3707 E SOUTHERN AVE STE 1023
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-6202
Mailing Address - Country:US
Mailing Address - Phone:480-795-1515
Mailing Address - Fax:480-597-1723
Practice Address - Street 1:3707 E SOUTHERN AVE STE 1023
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-6202
Practice Address - Country:US
Practice Address - Phone:480-795-1515
Practice Address - Fax:480-597-1723
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-10
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ080154Medicaid
AZOTC11031OtherSTATE LICENCURE