Healthcare Provider Details

I. General information

NPI: 1487784450
Provider Name (Legal Business Name): MOLLEN IMMUNIZATION CLINICS OF NORTH AMERICA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 11/14/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4602 N 16TH ST SUITE 200
PHOENIX AZ
85016-5189
US

IV. Provider business mailing address

4602 N 16TH ST SUITE 200
PHOENIX AZ
85016-5189
US

V. Phone/Fax

Practice location:
  • Phone: 602-264-9806
  • Fax: 602-264-9846
Mailing address:
  • Phone: 602-264-9806
  • Fax: 602-264-9846

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. BEVERLY A WATTS
Title or Position: SR. VICE PRESIDENT
Credential:
Phone: 602-264-9806