Provider Demographics
NPI:1417597857
Name:MD24 SAFE HARBOR MI, LLC.
Entity Type:Organization
Organization Name:MD24 SAFE HARBOR MI, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LINH
Authorized Official - Middle Name:
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-374-7774
Mailing Address - Street 1:14780 W MOUNTAIN VIEW BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-7280
Mailing Address - Country:US
Mailing Address - Phone:623-374-7774
Mailing Address - Fax:855-959-1911
Practice Address - Street 1:14780 W MOUNTAIN VIEW BLVD STE 110
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-7280
Practice Address - Country:US
Practice Address - Phone:623-374-7774
Practice Address - Fax:855-959-1911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-14
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ11585425Medicaid