Provider Demographics
NPI:1356834642
Name:CANYON MEDICAL CLINIC LLC
Entity Type:Organization
Organization Name:CANYON MEDICAL CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:ERIC
Authorized Official - Last Name:MOTL
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C, MPAS
Authorized Official - Phone:218-371-9340
Mailing Address - Street 1:14534 W HIDDEN TERRACE LOOP
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD PARK
Mailing Address - State:AZ
Mailing Address - Zip Code:85340-0989
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:34501 S OLD BLACK CANYON HWY # 1
Practice Address - Street 2:
Practice Address - City:BLACK CANYON CITY
Practice Address - State:AZ
Practice Address - Zip Code:85324
Practice Address - Country:US
Practice Address - Phone:623-374-5070
Practice Address - Fax:623-374-5068
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-11
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1588081087Medicaid
AZ912701Medicaid