Provider Demographics
NPI:1285242560
Name:GROWING SPACE LLC
Entity type:Organization
Organization Name:GROWING SPACE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JOURNE
Authorized Official - Middle Name:
Authorized Official - Last Name:DOMEK
Authorized Official - Suffix:
Authorized Official - Credentials:OTL
Authorized Official - Phone:480-347-8265
Mailing Address - Street 1:3940 S 79TH DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85043-1694
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3940 S 79TH DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85043-1694
Practice Address - Country:US
Practice Address - Phone:480-347-8265
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-22
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center