Healthcare Provider Details

I. General information

NPI: 1164042404
Provider Name (Legal Business Name): MOBILE CARE DIRECT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2020
Last Update Date: 04/16/2020
Certification Date: 04/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5060 N 19TH AVE STE 102
PHOENIX AZ
85015-3211
US

IV. Provider business mailing address

530 E MCDOWELL RD STE 107-437
PHOENIX AZ
85004-1549
US

V. Phone/Fax

Practice location:
  • Phone: 480-576-8283
  • Fax: 480-434-6607
Mailing address:
  • Phone: 480-576-8283
  • Fax: 480-434-6607

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2081H0002X
TaxonomyHospice and Palliative Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: ADAM BAGLEY
Title or Position: MANAGER
Credential:
Phone: 808-312-8059