Provider Demographics
NPI:1104381466
Name:MESA MULTISPECIALTY, LLC
Entity Type:Organization
Organization Name:MESA MULTISPECIALTY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JEREMIAH
Authorized Official - Middle Name:
Authorized Official - Last Name:FABER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-258-3635
Mailing Address - Street 1:81 W. GUADALUPE ROAD
Mailing Address - Street 2:SUITE 112
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85233
Mailing Address - Country:US
Mailing Address - Phone:480-659-1404
Mailing Address - Fax:602-635-3863
Practice Address - Street 1:81 W. GUADALUPE ROAD
Practice Address - Street 2:SUITE 112
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85233
Practice Address - Country:US
Practice Address - Phone:480-659-1404
Practice Address - Fax:602-635-3863
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-31
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory