=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437592433
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAYA MEDICAL SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2013
-----------------------------------------------------
Last Update Date | 04/10/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2908 W. CAMELBACK RD.
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85017
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-249-9070
-----------------------------------------------------
Fax | 602-249-9165
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2908 W. CAMELBACK RD.
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85017
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-249-9070
-----------------------------------------------------
Fax | 602-249-9165
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | IME OKON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 602-249-9070
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------