MEDICARE: UCXTRA UMBRELLA, 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	261QE0002X	Emergency Care Clinic/Center	1518952365	AZ
2	261QU0200X	Urgent Care Clinic/Center

General Provider Information

NPI Number	:	1538565049
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UCXTRA UMBRELLA, LLC

Provider Business Mailing Address
First Line	:	1250 S CLEARVIEW AVE
Second Line	:	SUITE 100
City	:	MESA
State	:	AZ
Zip	:	85209-3378
Country	:	US
Telephone Number	:	480-988-9108
Fax Number	:	480-813-4460

Provider Business Practice Location Address
First Line	:	6702 W BETHANY HOME RD
Second Line	:	SUITE 13, 14 & 15
City	:	GLENDALE
State	:	AZ
Zip	:	85303-4402
Country	:	US
Telephone Number	:	623-435-7000
Fax Number	:	623-435-3947

Authorized Official
Title or Position	:	DIRECTOR OF OPERATIONS
Name	:	MRS. AMY M. PANDURO
Credential	:
Telephone Number	:	480-663-2432

Provider Enumeration Date	:	11/10/2014
Last Update Date	:	04/03/2015

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