Provider Demographics
NPI:1427594308
Name:MEDICAL MALL OF ARIZONA
Entity Type:Organization
Organization Name:MEDICAL MALL OF ARIZONA
Other - Org Name:MEDICAL MALL OF ARIZONA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:480-999-0049
Mailing Address - Street 1:4902 S VAL VISTA DR
Mailing Address - Street 2:SUITE B106
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85298-7325
Mailing Address - Country:US
Mailing Address - Phone:480-999-0049
Mailing Address - Fax:
Practice Address - Street 1:8035 E BROWN RD BLDG 4
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85207-3902
Practice Address - Country:US
Practice Address - Phone:480-999-0049
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-16
Last Update Date:2017-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty