Provider Demographics
NPI:1417679648
Name:NATIVE RISING OF ARIZONA LLC
Entity Type:Organization
Organization Name:NATIVE RISING OF ARIZONA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ADEBOWALE
Authorized Official - Middle Name:M
Authorized Official - Last Name:OKE
Authorized Official - Suffix:
Authorized Official - Credentials:ETC
Authorized Official - Phone:714-933-6190
Mailing Address - Street 1:3420 E SHEA BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-3348
Mailing Address - Country:US
Mailing Address - Phone:714-933-6190
Mailing Address - Fax:
Practice Address - Street 1:1717 W NORTHERN AVE STE 200
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-5478
Practice Address - Country:US
Practice Address - Phone:714-933-6190
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-14
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center