Provider Demographics
NPI:1639595754
Name:PASSPORT HEALTH HOLDINGS, LLC
Entity Type:Organization
Organization Name:PASSPORT HEALTH HOLDINGS, LLC
Other - Org Name:PASSPORT HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF FINANCE
Authorized Official - Prefix:MR
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 1:118 HUXLEY RD STE 1
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37922-3183
Practice Address - Country:US
Practice Address - Phone:877-358-8648
Practice Address - Fax:877-877-8675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-13
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive MedicineGroup - Single Specialty