Healthcare Provider Details

I. General information

NPI: 1427594308
Provider Name (Legal Business Name): MEDICAL MALL OF ARIZONA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2017
Last Update Date: 01/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8035 E BROWN RD BLDG 4
MESA AZ
85207-3902
US

IV. Provider business mailing address

4902 S VAL VISTA DR SUITE B106
GILBERT AZ
85298-7325
US

V. Phone/Fax

Practice location:
  • Phone: 480-999-0049
  • Fax:
Mailing address:
  • Phone: 480-999-0049
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: KRISTINE SMITH
Title or Position: MEMBER
Credential: OTR/L
Phone: 480-999-0049