Provider Demographics
NPI:1538662077
Name:MARYVALE MEDICAL LLC
Entity Type:Organization
Organization Name:MARYVALE MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO/MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHALLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:WAYCHOFF
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:480-634-6400
Mailing Address - Street 1:3724 N 3RD ST STE 301
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2035
Mailing Address - Country:US
Mailing Address - Phone:480-634-6400
Mailing Address - Fax:480-404-9649
Practice Address - Street 1:7141 W THOMAS RD STE 101
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85033-5518
Practice Address - Country:US
Practice Address - Phone:480-634-6400
Practice Address - Fax:480-404-9649
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-12
Last Update Date:2018-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty