Healthcare Provider Details

I. General information

NPI: 1609770866
Provider Name (Legal Business Name): MAIN STREET MEDICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2026
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21029 W MAIN ST
BUCKEYE AZ
85396-3527
US

IV. Provider business mailing address

21029 W MAIN ST
BUCKEYE AZ
85396-3527
US

V. Phone/Fax

Practice location:
  • Phone: 623-248-6404
  • Fax: 623-213-8541
Mailing address:
  • Phone: 623-248-6404
  • Fax: 623-213-8541

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number StateNULL

VIII. Authorized Official

Name: JENNIFER HERRERA
Title or Position: MEDICAL DIRECTOR
Credential: FNP-C
Phone: 623-248-6404