Provider Demographics
NPI:1457010019
Name:BORTIS, DEREK J
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:J
Last Name:BORTIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26204 N FERNBUSH DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85083-1625
Mailing Address - Country:US
Mailing Address - Phone:480-826-5087
Mailing Address - Fax:
Practice Address - Street 1:2405 W FLORENTINE RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85086-6602
Practice Address - Country:US
Practice Address - Phone:480-826-5087
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-10
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility