Provider Demographics
NPI:1821091158
Name:ARIZONA MEDSOURCE HOLDINGS LLC
Entity Type:Organization
Organization Name:ARIZONA MEDSOURCE HOLDINGS LLC
Other - Org Name:H&L MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KEENE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-292-8496
Mailing Address - Street 1:14747 N NORTHSIGHT BLVD STE 111 PMB 328
Mailing Address - Street 2:
Mailing Address - City:SSOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260
Mailing Address - Country:US
Mailing Address - Phone:480-292-8496
Mailing Address - Fax:866-561-8331
Practice Address - Street 1:8260 E RAINTREE DR STE 202
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-2516
Practice Address - Country:US
Practice Address - Phone:480-292-8496
Practice Address - Fax:866-561-8331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-31
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ07502892T332B00000X
AZ332B00000X
332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ324541Medicaid
AZ7448550001Medicare NSC