Provider Demographics
NPI:1295009561
Name:HEARTFIT FOR DUTY LLC
Entity Type:Organization
Organization Name:HEARTFIT FOR DUTY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MRS
Authorized Official - First Name:KEPRA
Authorized Official - Middle Name:L
Authorized Official - Last Name:JACK
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:602-402-5090
Mailing Address - Street 1:4192 E PALM BEACH DR
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85249-7398
Mailing Address - Country:US
Mailing Address - Phone:602-402-5090
Mailing Address - Fax:
Practice Address - Street 1:633 E RAY RD
Practice Address - Street 2:SUITE 101
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296-4200
Practice Address - Country:US
Practice Address - Phone:480-999-7911
Practice Address - Fax:480-499-5829
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-02
Last Update Date:2013-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
AZAP3059363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty