Provider Demographics
NPI:1508416918
Name:EXR4 MEDICAL LLC
Entity Type:Organization
Organization Name:EXR4 MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:
Authorized Official - Last Name:BUCKNER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:602-421-2730
Mailing Address - Street 1:4540 E BASELINE RD STE 105
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-4616
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1984 E BASELINE RD
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-1535
Practice Address - Country:US
Practice Address - Phone:480-272-8944
Practice Address - Fax:480-930-4018
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-17
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory SurgicalGroup - Single Specialty