Provider Demographics
NPI:1952771024
Name:EAST VALLEY JOINT CLINIC LLC
Entity Type:Organization
Organization Name:EAST VALLEY JOINT CLINIC LLC
Other - Org Name:DIVINE IV AND WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JOOST
Authorized Official - Middle Name:
Authorized Official - Last Name:BERKHOUT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-718-1444
Mailing Address - Street 1:3930 S ALMA SCHOOL RD STE 10
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85248-4510
Mailing Address - Country:US
Mailing Address - Phone:480-718-1444
Mailing Address - Fax:480-718-7729
Practice Address - Street 1:3930 S ALMA SCHOOL RD STE 10
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85248-4510
Practice Address - Country:US
Practice Address - Phone:480-718-1444
Practice Address - Fax:480-718-7729
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-02
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP5244363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ100091Medicaid