Provider Demographics
NPI: | 1609287887 |
---|---|
Name: | BANNER HEALTH |
Entity Type: | Organization |
Organization Name: | BANNER HEALTH |
Other - Org Name: | BANNER PRIMARY CARE SUN CITY WEST |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | CFO |
Authorized Official - Prefix: | |
Authorized Official - First Name: | DENNIS |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | LARAWAY |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 602-747-4000 |
Mailing Address - Street 1: | 2901 N CENTRAL AVE STE 160 |
Mailing Address - Street 2: | |
Mailing Address - City: | PHOENIX |
Mailing Address - State: | AZ |
Mailing Address - Zip Code: | 85012-2702 |
Mailing Address - Country: | US |
Mailing Address - Phone: | |
Mailing Address - Fax: | |
Practice Address - Street 1: | 14416 W MEEKER BLVD |
Practice Address - Street 2: | BUILDING C SUITE 200 |
Practice Address - City: | SUN CITY |
Practice Address - State: | AZ |
Practice Address - Zip Code: | 85375-5284 |
Practice Address - Country: | US |
Practice Address - Phone: | 623-876-3971 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | Yes |
Parent Organization LBN: | MEDVANTX, INC. |
Parent Organization TIN: | <UNAVAIL> |
Enumeration Date: | 2014-05-09 |
Last Update Date: | 2022-01-31 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
AZ | 34302 | 332900000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 332900000X | Suppliers | Non-Pharmacy Dispensing Site |