Provider Demographics
NPI:1386028421
Name:UCXTRA UMBRELLA, LLC
Entity Type:Organization
Organization Name:UCXTRA UMBRELLA, LLC
Other - Org Name:URGENT CARE EXTRA AZ
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF ADMIN OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:PANDURO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-663-2432
Mailing Address - Street 1:35945 N GARY RD
Mailing Address - Street 2:
Mailing Address - City:SAN TAN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85143
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1250 S CLEARVIEW AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85209
Practice Address - Country:US
Practice Address - Phone:480-988-9108
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-18
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ412931Medicaid
AZ412931Medicaid