Provider Demographics
NPI:1417250671
Name:PHOENIX VA HEALTHCARE SYSTEMS
Entity Type:Organization
Organization Name:PHOENIX VA HEALTHCARE SYSTEMS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITAN
Authorized Official - Prefix:MS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:LESCHAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-277-5551
Mailing Address - Street 1:9258 E 27TH ST
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85710-7405
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9258 E 27TH ST
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85710-7405
Practice Address - Country:US
Practice Address - Phone:520-403-2757
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-09
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1035321286500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes286500000XHospitalsMilitary Hospital