Healthcare Provider Details

I. General information

NPI: 1548037732
Provider Name (Legal Business Name): MEDICALLY DIRECTED CARE CLINIC PHOENIX, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2023
Last Update Date: 12/07/2023
Certification Date: 12/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 S HIGLEY RD
GILBERT AZ
85296-4798
US

IV. Provider business mailing address

3714 S PONDEROSA DR
GILBERT AZ
85297-7422
US

V. Phone/Fax

Practice location:
  • Phone: 480-870-1414
  • Fax:
Mailing address:
  • Phone: 602-326-5932
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. JEFFREY LORAN WEBB
Title or Position: OWNER
Credential:
Phone: 602-326-5932