Provider Demographics
NPI:1891964664
Name:FS CAMELBACK LLC
Entity type:Organization
Organization Name:FS CAMELBACK LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:P
Authorized Official - Last Name:JACOBY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:602-241-9300
Mailing Address - Street 1:1650 E CAMELBACK RD
Mailing Address - Street 2:SUITE 175
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-3941
Mailing Address - Country:US
Mailing Address - Phone:602-241-9300
Mailing Address - Fax:602-241-9305
Practice Address - Street 1:1650 E CAMELBACK RD
Practice Address - Street 2:SUITE 175
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-3941
Practice Address - Country:US
Practice Address - Phone:602-241-9300
Practice Address - Fax:602-241-9305
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-26
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ332BC3200X332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ=========OtherFEDERAL EIN