Provider Demographics
NPI:1750124459
Name:SIR ISAAC LLC
Entity type:Organization
Organization Name:SIR ISAAC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MASSA
Authorized Official - Middle Name:KIAWOIN
Authorized Official - Last Name:LAVANT
Authorized Official - Suffix:
Authorized Official - Credentials:OWNER
Authorized Official - Phone:763-639-1269
Mailing Address - Street 1:18275 N 59TH AVE STE 128
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-1252
Mailing Address - Country:US
Mailing Address - Phone:763-639-1269
Mailing Address - Fax:602-938-2283
Practice Address - Street 1:18275 N 59TH AVE STE 128
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-1252
Practice Address - Country:US
Practice Address - Phone:763-639-1269
Practice Address - Fax:602-938-2283
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-18
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service