Provider Demographics
NPI:1609576123
Name:KICK START INTEGRATIVE HEALTH PLLC
Entity Type:Organization
Organization Name:KICK START INTEGRATIVE HEALTH PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:B
Authorized Official - Last Name:ANTHONY
Authorized Official - Suffix:
Authorized Official - Credentials:DC, FNP-C
Authorized Official - Phone:623-776-6633
Mailing Address - Street 1:6320 W UNION HILLS DR STE B1500
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-1062
Mailing Address - Country:US
Mailing Address - Phone:623-776-6633
Mailing Address - Fax:602-428-6860
Practice Address - Street 1:6320 W UNION HILLS DR STE B1500
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-1062
Practice Address - Country:US
Practice Address - Phone:623-776-6633
Practice Address - Fax:602-428-6860
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-03
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty