Provider Demographics
NPI:1417433236
Name:SPECTRUM MEDICAL CARE CENTER
Entity Type:Organization
Organization Name:SPECTRUM MEDICAL CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:FRANKS-MITCHELL JAUREGUI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-930-4353
Mailing Address - Street 1:52 E MONTEREY WAY STE A
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2628
Mailing Address - Country:US
Mailing Address - Phone:480-930-4353
Mailing Address - Fax:480-930-4353
Practice Address - Street 1:52 E MONTEREY WAY STE A
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-2628
Practice Address - Country:US
Practice Address - Phone:480-930-4353
Practice Address - Fax:480-930-4353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-15
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ24745261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ24745OtherAZ LICENSE
AZ382763Medicaid
AZAZ0800990OtherBCBS
AZAZ0800990OtherBCBS