Healthcare Provider Details

I. General information

NPI: 1164619821
Provider Name (Legal Business Name): BLACK CANYON MEDICAL L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2007
Last Update Date: 03/09/2020
Certification Date: 03/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17301 E SPRING VALLEY RD
MAYER AZ
86333-4263
US

IV. Provider business mailing address

17301 E SPRING VALLEY RD STE F
MAYER AZ
86333-4263
US

V. Phone/Fax

Practice location:
  • Phone: 928-632-4909
  • Fax: 928-632-4973
Mailing address:
  • Phone: 928-710-5851
  • Fax: 928-632-4973

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number3297
License Number StateAZ

VIII. Authorized Official

Name: KERRY D MALIN
Title or Position: PROVIDER
Credential: PA
Phone: 928-710-5851