Provider Demographics
NPI:1548462716
Name:ARIZONA MEDICAL BOUTIQUE, LLC
Entity type:Organization
Organization Name:ARIZONA MEDICAL BOUTIQUE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:SHUREE
Authorized Official - Middle Name:KRISTINE
Authorized Official - Last Name:OLDEHOEFT
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:480-766-0550
Mailing Address - Street 1:35017 N 30TH DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85086-3224
Mailing Address - Country:US
Mailing Address - Phone:480-766-0550
Mailing Address - Fax:623-581-7499
Practice Address - Street 1:35017 N 30TH DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85086-3224
Practice Address - Country:US
Practice Address - Phone:480-766-0550
Practice Address - Fax:623-581-7499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3164251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare