1659645679 NPI number — AFC PHYSICAL MEDICINE OF MESA, PLLC

Table of content: (NPI 1659645679)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659645679 NPI number — AFC PHYSICAL MEDICINE OF MESA, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AFC PHYSICAL MEDICINE OF MESA, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1659645679
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/08/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1839 S ALMA SCHOOL RD STE 354
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MESA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85210-3028
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-726-2287
Provider Business Mailing Address Fax Number:
888-316-9272

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3130 E BASELINE RD
Provider Second Line Business Practice Location Address:
SUITE 107
Provider Business Practice Location Address City Name:
MESA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85204-7290
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-345-1980
Provider Business Practice Location Address Fax Number:
480-926-1721
Provider Enumeration Date:
03/08/2012

Additional Information

Authorized Official

Authorized Official Last Name:
BOCK
Authorized Official First Name:
JOSHUA
Authorized Official Middle Name:
F.
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
480-726-2287

Provider Taxonomy Codes

  • Taxonomy code: 208100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332B00000X , with the licence number: 7046960001 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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