Provider Demographics
NPI:1134345937
Name:PDA HOLDINGS, LLC
Entity type:Organization
Organization Name:PDA HOLDINGS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:J
Authorized Official - Last Name:TRUJILLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-253-6600
Mailing Address - Street 1:1701 E THOMAS RD STE 204
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-7675
Mailing Address - Country:US
Mailing Address - Phone:602-253-6600
Mailing Address - Fax:602-279-0821
Practice Address - Street 1:1701 E THOMAS RD #204
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016
Practice Address - Country:US
Practice Address - Phone:602-253-6600
Practice Address - Fax:602-279-0821
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ232643OtherAHCCCS PROVIDER ID