Healthcare Provider Details

I. General information

NPI: 1083667521
Provider Name (Legal Business Name): ADOBE E.N.T. & ALLERGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 10/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 N. LINDSAY RD STE. #2
MESA AZ
85213
US

IV. Provider business mailing address

116 N. LINDSAY RD. STE #2
MESA AZ
85213
US

V. Phone/Fax

Practice location:
  • Phone: 480-649-8150
  • Fax: 480-649-9905
Mailing address:
  • Phone: 480-649-8150
  • Fax: 480-649-9905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number2767
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number2767
License Number StateAZ

VIII. Authorized Official

Name: RICHARD ALAN MICKLE
Title or Position: OWNER
Credential: D.O.
Phone: 480-649-8150