Provider Demographics
NPI:1114643905
Name:DYNASTY OF SELAH INTEGRATED HEALTH SERVICES PLLC
Entity Type:Organization
Organization Name:DYNASTY OF SELAH INTEGRATED HEALTH SERVICES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OF ENTITY
Authorized Official - Prefix:
Authorized Official - First Name:TARA
Authorized Official - Middle Name:C
Authorized Official - Last Name:CHERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-231-3593
Mailing Address - Street 1:1846 E INNOVATION PARK DR
Mailing Address - Street 2:
Mailing Address - City:ORO VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85755-1963
Mailing Address - Country:US
Mailing Address - Phone:770-231-3593
Mailing Address - Fax:
Practice Address - Street 1:1846 E INNOVATION PARK DR
Practice Address - Street 2:
Practice Address - City:ORO VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85755-1963
Practice Address - Country:US
Practice Address - Phone:770-231-3593
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-13
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty