Provider Demographics
NPI:1326152653
Name:MED CHOICE ONE MEDICAL GROUP AND SUPPLIER LLC
Entity Type:Organization
Organization Name:MED CHOICE ONE MEDICAL GROUP AND SUPPLIER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:AKANINYENE
Authorized Official - Middle Name:W
Authorized Official - Last Name:ETUK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-266-4633
Mailing Address - Street 1:635 W INDIAN SCHOOL RD
Mailing Address - Street 2:SUITE 101B
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-3117
Mailing Address - Country:US
Mailing Address - Phone:602-266-4633
Mailing Address - Fax:602-266-4634
Practice Address - Street 1:635 W INDIAN SCHOOL RD
Practice Address - Street 2:SUITE 101B
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-3117
Practice Address - Country:US
Practice Address - Phone:602-266-4633
Practice Address - Fax:602-266-4634
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ20064003332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ5480190001Medicare ID - Type UnspecifiedPROVIDER NUMBER