Provider Demographics
NPI:1346619087
Name:MARICOPA MOBILE MED, INC.
Entity Type:Organization
Organization Name:MARICOPA MOBILE MED, INC.
Other - Org Name:MARICOPA MOBILE MED
Other - Org Type:Other Name
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ELWIN
Authorized Official - Last Name:BUCKWALTER
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:520-858-6181
Mailing Address - Street 1:20548 N DONITHAN WAY
Mailing Address - Street 2:
Mailing Address - City:MARICOPA
Mailing Address - State:AZ
Mailing Address - Zip Code:85138-2466
Mailing Address - Country:US
Mailing Address - Phone:520-858-6181
Mailing Address - Fax:
Practice Address - Street 1:2902 W CLARENDON AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85017-4609
Practice Address - Country:US
Practice Address - Phone:520-858-6181
Practice Address - Fax:866-624-8718
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-23
Last Update Date:2016-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care