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General NPI Number Information
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NPI Number | 1699674143
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Entity Type | Organization
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Legal Business Name | MESA PRIMARY CARE LLC
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Dates
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Enumeration Date | 11/02/2026
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Last Update Date | 11/02/2026
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Provider Practice Location Address
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Address Line | 864 W SOUTHERN AVE
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City | MESA
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State | AZ
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Zip | 85210-4900
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Country | US
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Telephone | 602-690-6901
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Fax |
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Provider Business Mailing Address
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Address Line | 864 W SOUTHERN AVE
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City | MESA
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State | AZ
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Zip | 85210-4900
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Country | US
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Telephone | 602-690-6901
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | TAHLIL SCOTT
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Credential |
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Telephone | 480-478-0418
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TP2701X
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Taxonomy Name | Group Psychotherapy Psychologist
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License Number |
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License Number State |
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