Provider Demographics
NPI:1760188098
Name:PDA HOLDINGS WEST, LLC
Entity Type:Organization
Organization Name:PDA HOLDINGS WEST, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JERAMY
Authorized Official - Middle Name:
Authorized Official - Last Name:TARWATER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-253-6600
Mailing Address - Street 1:5109 W THOMAS RD STE 300
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85031-3944
Mailing Address - Country:US
Mailing Address - Phone:602-472-3553
Mailing Address - Fax:602-687-9844
Practice Address - Street 1:5109 W THOMAS RD STE 300
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85031-3944
Practice Address - Country:US
Practice Address - Phone:602-472-3553
Practice Address - Fax:602-687-9844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-07
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental