Healthcare Provider Details

I. General information

NPI: 1770148322
Provider Name (Legal Business Name): EQUALITY MEDICAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2019
Last Update Date: 09/25/2020
Certification Date: 09/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9020 W THOMAS RD
PHOENIX AZ
85037-3234
US

IV. Provider business mailing address

4220 N 20TH AVE
PHOENIX AZ
85015-5124
US

V. Phone/Fax

Practice location:
  • Phone: 580-686-0282
  • Fax:
Mailing address:
  • Phone: 602-889-9401
  • Fax: 602-889-9404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ROSE MATA-ESPINOZA
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 602-687-8219