Healthcare Provider Details

I. General information

NPI: 1508416918
Provider Name (Legal Business Name): EXR4 MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2019
Last Update Date: 07/15/2020
Certification Date: 07/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1984 E BASELINE RD
TEMPE AZ
85283-1535
US

IV. Provider business mailing address

4540 E BASELINE RD STE 105
MESA AZ
85206-4616
US

V. Phone/Fax

Practice location:
  • Phone: 480-272-8944
  • Fax: 480-930-4018
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JEREMY BUCKNER
Title or Position: MEMBER
Credential: DC
Phone: 602-421-2730