Provider Demographics
NPI:1447790985
Name:SOUTHLAND GERIATRIC & PALLIATIVE CARE, LLC
Entity Type:Organization
Organization Name:SOUTHLAND GERIATRIC & PALLIATIVE CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:OWEN
Authorized Official - Middle Name:
Authorized Official - Last Name:OWENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-845-8000
Mailing Address - Street 1:4527 N 16TH ST
Mailing Address - Street 2:STE 104
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-5352
Mailing Address - Country:US
Mailing Address - Phone:480-800-4800
Mailing Address - Fax:480-699-2914
Practice Address - Street 1:4527 N 16TH ST
Practice Address - Street 2:STE 104
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-5352
Practice Address - Country:US
Practice Address - Phone:480-800-4800
Practice Address - Fax:480-699-2914
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-02
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ006329208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty