Provider Demographics
NPI:1972085587
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 DRIVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85255-7801
Mailing Address - Country:US
Mailing Address - Phone:877-358-8648
Mailing Address - Fax:877-877-6875
Practice Address - Street 1:3375 E. CAPITAL CIRCLE NE BLDG E
Practice Address - Street 2:SUITE 3
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-3778
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:2018-08-30
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive MedicineGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty