Healthcare Provider Details

I. General information

NPI: 1609206549
Provider Name (Legal Business Name): MIRAGE MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2013
Last Update Date: 11/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10046 N METRO PKWY W SUITE 115
PHOENIX AZ
85051-1437
US

IV. Provider business mailing address

1001 E WARNER RD SUITE 107
TEMPE AZ
85284-3224
US

V. Phone/Fax

Practice location:
  • Phone: 602-674-5515
  • Fax: 602-674-3029
Mailing address:
  • Phone: 480-264-3744
  • Fax: 480-264-2075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number5988
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP4986
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code364SF0001X
TaxonomyFamily Health Clinical Nurse Specialist
License NumberAP2828
License Number StateAZ

VIII. Authorized Official

Name: DR. JEREMY R BUCKNER
Title or Position: OWNER
Credential: D.C.
Phone: 602-421-2730