Provider Demographics
NPI:1235125840
Name:MKRP INDUSTRIES INCORPORATION
Entity Type:Organization
Organization Name:MKRP INDUSTRIES INCORPORATION
Other - Org Name:CANYON FAMILY PHYSICIANS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:PICKERING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-889-7550
Mailing Address - Street 1:2451 E BASELINE RD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-2471
Mailing Address - Country:US
Mailing Address - Phone:480-507-2213
Mailing Address - Fax:480-507-0677
Practice Address - Street 1:2451 E BASELINE RD
Practice Address - Street 2:SUITE 130
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-2471
Practice Address - Country:US
Practice Address - Phone:480-507-2213
Practice Address - Fax:480-507-0677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-20
Last Update Date:2008-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ33546302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ2Z2444OtherHEALTH NET
AZ916562Medicaid
AZ2Z2444OtherHEALTH NET
AZE81200Medicare UPIN