Provider Demographics
NPI:1205476868
Name:BOWSER'S GARDEN LLC
Entity type:Organization
Organization Name:BOWSER'S GARDEN LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LUANNE
Authorized Official - Middle Name:TAKACS
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, ANP-BC, MBA
Authorized Official - Phone:520-340-8686
Mailing Address - Street 1:14609 N 60TH AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85306-3805
Mailing Address - Country:US
Mailing Address - Phone:520-340-8686
Mailing Address - Fax:480-738-4025
Practice Address - Street 1:2400 W DUNLAP AVE STE 125
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-2885
Practice Address - Country:US
Practice Address - Phone:520-340-8686
Practice Address - Fax:623-738-4025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-13
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1073849360OtherINDIVIDUAL NP
AZ616876Medicaid