Provider Demographics
NPI:1750053542
Name:MESKHISHVILI, DAVID
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:MESKHISHVILI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1615 E LE MARCHE AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85022-3359
Mailing Address - Country:US
Mailing Address - Phone:602-601-4201
Mailing Address - Fax:602-601-4201
Practice Address - Street 1:1615 E LE MARCHE AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85022-3359
Practice Address - Country:US
Practice Address - Phone:602-601-4201
Practice Address - Fax:602-601-4201
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-30
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL11948310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
--OtherN/A