Provider Demographics
NPI:1114233079
Name:1203 PALLOVERDE LLC
Entity Type:Organization
Organization Name:1203 PALLOVERDE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HACKETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-288-0422
Mailing Address - Street 1:1203 W PALO VERDE DR
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-2358
Mailing Address - Country:US
Mailing Address - Phone:202-288-0422
Mailing Address - Fax:
Practice Address - Street 1:1203 W PALO VERDE DR
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-2358
Practice Address - Country:US
Practice Address - Phone:202-288-0422
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-28
Last Update Date:2010-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL7815H261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care