Provider Demographics
NPI:1619488103
Name:MOLLED TRAVEL VACCINES, PLLC
Entity Type:Organization
Organization Name:MOLLED TRAVEL VACCINES, PLLC
Other - Org Name:PASSPORT HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:FISHBURN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-646-9020
Mailing Address - Street 1:668 N 44TH ST
Mailing Address - Street 2:SUITE 100W
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85008-6507
Mailing Address - Country:US
Mailing Address - Phone:877-358-8648
Mailing Address - Fax:480-546-3421
Practice Address - Street 1:14985 W. BELL ROAD
Practice Address - Street 2:BUILDING 12-A #100
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-3231
Practice Address - Country:US
Practice Address - Phone:877-358-8648
Practice Address - Fax:877-877-6875
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-24
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Single Specialty