Provider Demographics
NPI:1609610666
Name:DANJER BLAZE REIGN LLC
Entity type:Organization
Organization Name:DANJER BLAZE REIGN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:SEARS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-615-0876
Mailing Address - Street 1:530 E HUNT HWY STE 130 PMB #493
Mailing Address - Street 2:
Mailing Address - City:SAN TAN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85143-6581
Mailing Address - Country:US
Mailing Address - Phone:480-256-2958
Mailing Address - Fax:
Practice Address - Street 1:530 E HUNT HWY STE 130 PMB #493
Practice Address - Street 2:
Practice Address - City:SAN TAN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85143-6581
Practice Address - Country:US
Practice Address - Phone:480-256-2958
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-24
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty