Healthcare Provider Details

I. General information

NPI: 1356834642
Provider Name (Legal Business Name): CANYON MEDICAL CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2018
Last Update Date: 08/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34501 S OLD BLACK CANYON HWY # 1
BLACK CANYON CITY AZ
85324
US

IV. Provider business mailing address

14534 W HIDDEN TERRACE LOOP
LITCHFIELD PARK AZ
85340-0989
US

V. Phone/Fax

Practice location:
  • Phone: 623-374-5070
  • Fax: 623-374-5068
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JOSHUA ERIC MOTL
Title or Position: PHYSICIAN ASSISTANT
Credential: PA-C, MPAS
Phone: 218-371-9340