Healthcare Provider Details

I. General information

NPI: 1306089347
Provider Name (Legal Business Name): MUA CENTER OF PHOENIX LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2009
Last Update Date: 04/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16222 N 59TH AVE STE A-100
GLENDALE AZ
85306-1701
US

IV. Provider business mailing address

PO BOX 864483
ORLANDO FL
32886-4483
US

V. Phone/Fax

Practice location:
  • Phone: 941-360-1566
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CARL R NOBACK
Title or Position: OWNER
Credential: MD
Phone: 941-360-1566