=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124618509
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIND CARE MOBILE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/20/2021
-----------------------------------------------------
Last Update Date | 01/20/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8712 E VISTA BONITA DR
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85255-4299
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-980-9317
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3317 S HIGLEY RD STE 114-466
-----------------------------------------------------
City | GILBERT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85297-5465
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-580-7035
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | ZAK CORONADO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 623-521-9113
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------