Healthcare Provider Details

I. General information

NPI: 1669509568
Provider Name (Legal Business Name): CENTRAL MESA MEDICAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 11/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 N CENTER ST
MESA AZ
85201-6629
US

IV. Provider business mailing address

204 N CENTER ST
MESA AZ
85201-6629
US

V. Phone/Fax

Practice location:
  • Phone: 480-962-0868
  • Fax: 480-962-7010
Mailing address:
  • Phone: 480-962-0868
  • Fax: 480-962-7010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number03289
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number21507
License Number StateAZ

VIII. Authorized Official

Name: SCOTT L MIRITELLO
Title or Position: PRESIDENT
Credential: D.C.
Phone: 480-962-0868