Provider Demographics
NPI:1477259356
Name:THAC, ROUT
Entity Type:Individual
Prefix:
First Name:ROUT
Middle Name:
Last Name:THAC
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 1:4911 W MALDONADO RD
Mailing Address - Street 2:
Mailing Address - City:LAVEEN
Mailing Address - State:AZ
Mailing Address - Zip Code:85339-8217
Mailing Address - Country:US
Mailing Address - Phone:480-275-1056
Mailing Address - Fax:
Practice Address - Street 1:4911 W MALDONADO RD
Practice Address - Street 2:
Practice Address - City:LAVEEN
Practice Address - State:AZ
Practice Address - Zip Code:85339-8217
Practice Address - Country:US
Practice Address - Phone:480-275-1056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-02
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
AZSLH10481251S00000X
AZ3031899343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No251S00000XAgenciesCommunity/Behavioral Health