Provider Demographics
NPI:1801444013
Name:PHYLOGENESIS FINANCIAL HOLDINGS LLC
Entity type:Organization
Organization Name:PHYLOGENESIS FINANCIAL HOLDINGS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOONSTRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-286-7907
Mailing Address - Street 1:771 S CORNWALL DR
Mailing Address - Street 2:
Mailing Address - City:APACHE JUNCTION
Mailing Address - State:AZ
Mailing Address - Zip Code:85120-4812
Mailing Address - Country:US
Mailing Address - Phone:480-286-7907
Mailing Address - Fax:
Practice Address - Street 1:7615 E BASELINE RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85209
Practice Address - Country:US
Practice Address - Phone:602-206-2017
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-30
Last Update Date:2019-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care