Provider Demographics
NPI:1609206549
Name:MIRAGE MEDICAL LLC
Entity Type:Organization
Organization Name:MIRAGE MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:R
Authorized Official - Last Name:BUCKNER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:602-421-2730
Mailing Address - Street 1:1001 E WARNER RD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85284-3224
Mailing Address - Country:US
Mailing Address - Phone:480-264-3744
Mailing Address - Fax:480-264-2075
Practice Address - Street 1:10046 N METRO PKWY W
Practice Address - Street 2:SUITE 115
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85051-1437
Practice Address - Country:US
Practice Address - Phone:602-674-5515
Practice Address - Fax:602-674-3029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-13
Last Update Date:2013-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ59882081P2900X
AZAP4986363LF0000X
AZAP2828364SF0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily HealthGroup - Multi-Specialty