=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083916969
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEDIPRO MEDICAL STAFFING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/25/2010
-----------------------------------------------------
Last Update Date | 11/25/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2651 W GUADALUPE RD
-----------------------------------------------------
City | MESA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85202-7249
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-398-4777
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4205 E CHAPAROSA WAY
-----------------------------------------------------
City | CAVE CREEK
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85331-3817
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | ALEXANDER R MALCOLM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 480-678-2593
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251J00000X
-----------------------------------------------------
Taxonomy Name | Nursing Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------