Provider Demographics
NPI:1144752759
Name:PROMEDISCH, LLC
Entity Type:Organization
Organization Name:PROMEDISCH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NP
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:MAGOFFIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-748-9106
Mailing Address - Street 1:39506 N DAISY MOUNTAIN DR
Mailing Address - Street 2:SUITE 122-169
Mailing Address - City:ANTHEM
Mailing Address - State:AZ
Mailing Address - Zip Code:85086-1663
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2525 W CAREFREE HWY STE 118
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85085-9302
Practice Address - Country:US
Practice Address - Phone:623-748-9106
Practice Address - Fax:602-429-8579
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-02
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP4802363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty