MEDICARE: EXR4 MEDICAL LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QA1903X	Ambulatory Surgical Clinic/Center

General Provider Information

NPI Number	:	1508416918
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EXR4 MEDICAL LLC

Provider Business Mailing Address
First Line	:	4540 E BASELINE RD STE 105
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85206-4616
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1984 E BASELINE RD
Second Line	:
City	:	TEMPE
State	:	AZ
Zip	:	85283-1535
Country	:	US
Telephone Number	:	480-272-8944
Fax Number	:	480-930-4018

Authorized Official
Title or Position	:	MEMBER
Name	:	JEREMY BUCKNER
Credential	:	DC
Telephone Number	:	602-421-2730

Provider Enumeration Date	:	09/17/2019
Last Update Date	:	07/15/2020

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