Provider Demographics
NPI:1518067446
Name:MESA OCCUPATIONAL & SPORTS MEDICINE
Entity Type:Organization
Organization Name:MESA OCCUPATIONAL & SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTRACT MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:FREDERICK
Authorized Official - Last Name:MOSLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-325-1100
Mailing Address - Street 1:2700 FARMINGTON AVE
Mailing Address - Street 2:BUILDING F AND G
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-4559
Mailing Address - Country:US
Mailing Address - Phone:505-325-1100
Mailing Address - Fax:
Practice Address - Street 1:2700 FARMINGTON AVE
Practice Address - Street 2:BUILDING F AND G
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-4559
Practice Address - Country:US
Practice Address - Phone:505-325-1100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization