Provider Demographics
NPI:1477970192
Name:PASSPORT HEALTH HOLDINGS, LLC.
Entity Type:Organization
Organization Name:PASSPORT HEALTH HOLDINGS, LLC.
Other - Org Name:PPH OHIO, LLC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:DOUG
Authorized Official - Middle Name:
Authorized Official - Last Name:SHACKELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-646-9024
Mailing Address - Street 1:8324 E HARTFORD DR
Mailing Address - Street 2:#200
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85255
Mailing Address - Country:US
Mailing Address - Phone:888-909-6551
Mailing Address - Fax:480-383-6567
Practice Address - Street 1:29 PLANTATION PARK DR
Practice Address - Street 2:B100 #117
Practice Address - City:BLUFFTON
Practice Address - State:SC
Practice Address - Zip Code:29910
Practice Address - Country:US
Practice Address - Phone:888-909-6551
Practice Address - Fax:480-383-6567
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-19
Last Update Date:2016-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center