Healthcare Provider Details

I. General information

NPI: 1174650295
Provider Name (Legal Business Name): DESERT CANYON FAMILY & SPORTS MEDICINE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6200 S MCCLINTOCK DR SUITE 9
TEMPE AZ
85283-3268
US

IV. Provider business mailing address

6200 S MCCLINTOCK DR SUITE 9
TEMPE AZ
85283-3268
US

V. Phone/Fax

Practice location:
  • Phone: 480-820-4305
  • Fax: 480-820-5540
Mailing address:
  • Phone: 480-820-4305
  • Fax: 480-820-5540

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MARY-LOUISE MULCAHY
Title or Position: ADMINISTRATOR
Credential: RN, MBA, BSN
Phone: 480-357-3904