Provider Demographics
NPI:1184346405
Name:PROUDLY ARIZONA LLC
Entity type:Organization
Organization Name:PROUDLY ARIZONA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ESRA
Authorized Official - Middle Name:A
Authorized Official - Last Name:KHALEEL
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:323-378-8797
Mailing Address - Street 1:4816 W BETHANY HOME RD APT 90
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85301-5233
Mailing Address - Country:US
Mailing Address - Phone:323-378-8797
Mailing Address - Fax:
Practice Address - Street 1:1717 W NORTHERN AVE STE 106
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-5400
Practice Address - Country:US
Practice Address - Phone:323-378-8797
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-13
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No342000000XTransportation ServicesTransportation Network Company