Healthcare Provider Details

I. General information

NPI: 1003111378
Provider Name (Legal Business Name): ARIZONA GRAND MEDICAL CENTER PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2011
Last Update Date: 02/07/2025
Certification Date: 02/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3777 CROSSINGS DR
PRESCOTT AZ
86305-7121
US

IV. Provider business mailing address

PO BOX 47729
PHOENIX AZ
85068-7729
US

V. Phone/Fax

Practice location:
  • Phone: 928-771-9693
  • Fax: 928-708-0505
Mailing address:
  • Phone: 623-934-5600
  • Fax: 623-934-5603

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MELISSA MAYORAL
Title or Position: ACCOUNTS MANAGER
Credential:
Phone: 602-820-4709