Provider Demographics
NPI:1164051900
Name:STATESERV MEDICAL OF PHOENIX LLC
Entity Type:Organization
Organization Name:STATESERV MEDICAL OF PHOENIX LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:ROODE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-633-7250
Mailing Address - Street 1:1201 SOUTH ALMA SCHOOL RD
Mailing Address - Street 2:SUITE 4000
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5234 W. MISSOURI
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85301
Practice Address - Country:US
Practice Address - Phone:877-633-7250
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-03
Last Update Date:2020-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies