Provider Demographics
NPI:1871026674
Name:SOUL SURGERY LLC
Entity Type:Organization
Organization Name:SOUL SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING COMPLIANCE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:REGINA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAKESPEARE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-554-5633
Mailing Address - Street 1:14362 N. FRANK LLOYD WRIGHT
Mailing Address - Street 2:#B111
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260
Mailing Address - Country:US
Mailing Address - Phone:480-912-3105
Mailing Address - Fax:480-912-3106
Practice Address - Street 1:14362 N. FRANK LLOYD WRIGHT
Practice Address - Street 2:#B111
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260
Practice Address - Country:US
Practice Address - Phone:480-912-3105
Practice Address - Fax:480-912-3106
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-07
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTC7755101YA0400X, 364SP0809X
101YA0400X, 324500000X, 364SP0809X
AZOTC8541251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilityGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, AdultGroup - Multi-Specialty