Provider Demographics
NPI:1215366406
Name:PASSPORT HEALTH HOLDINGS, LLC
Entity Type:Organization
Organization Name:PASSPORT HEALTH HOLDINGS, LLC
Other - Org Name:PASSPORT HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:FISHBURN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-646-9020
Mailing Address - Street 1:668 N 44TH ST
Mailing Address - Street 2:SUITE 100W
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85008-6507
Mailing Address - Country:US
Mailing Address - Phone:877-358-8648
Mailing Address - Fax:877-877-6875
Practice Address - Street 1:910 MAIN ST
Practice Address - Street 2:SUITE 352
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-5720
Practice Address - Country:US
Practice Address - Phone:877-358-8648
Practice Address - Fax:877-877-6875
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-07
Last Update Date:2022-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive MedicineGroup - Multi-Specialty