| Premium Legacy Healthcare Inc | |
|
5062 N 19th Ave Ste 102 Phoenix AZ 85015-3225 | |
| (773) 319-6420 | |
| Not Available |
| Full Name | Premium Legacy Healthcare Inc |
|---|---|
| Speciality | Clinic/Center |
| Location | 5062 N 19th Ave Ste 102, Phoenix, Arizona |
| Authorized Official Name and Position | Ona Ekhomu (CEO) |
| Authorized Official Contact | 7733196420 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Premium Legacy Healthcare Inc 11234 N 129th Way Scottsdale AZ 85259-4403 Ph: (773) 319-6420 | Premium Legacy Healthcare Inc 5062 N 19th Ave Ste 102 Phoenix AZ 85015-3225 Ph: (773) 319-6420 |
| NPI Number | 1184327249 |
|---|---|
| Provider Enumeration Date | 03/27/2023 |
| Last Update Date | 07/09/2025 |
| Certification Date | 07/09/2025 |
| Medicare PECOS PAC ID | 3173069879 |
|---|---|
| Medicare Enrollment ID | O20240718000166 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1184327249 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 101YA0400X | Counselor - Addiction (substance Use Disorder) | () | Secondary |
| 261QM0801X | Clinic/center - Mental Health (including Community Mental Health Center) | () | Primary |
| Provider Name | Christian M Azode |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1306492046 PECOS PAC ID: 6103252580 Enrollment ID: I20200203001686 |
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