Provider Demographics
NPI:1275257917
Name:ZKALA IC - MYRTLE
Entity Type:Organization
Organization Name:ZKALA IC - MYRTLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE LEADERSHIP
Authorized Official - Prefix:
Authorized Official - First Name:JAVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-777-8339
Mailing Address - Street 1:8050 N 19TH AVE STE 500
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85021-5160
Mailing Address - Country:US
Mailing Address - Phone:623-842-9000
Mailing Address - Fax:
Practice Address - Street 1:7112 N 55TH AVE STE C
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85301-0707
Practice Address - Country:US
Practice Address - Phone:602-842-9000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:Z'KALA, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-09-27
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)