Provider Demographics
NPI:1689035479
Name:MERIDIAN THERAPEUTICS CLINIC LLC
Entity Type:Organization
Organization Name:MERIDIAN THERAPEUTICS CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ NURSE PRACTITIONER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMARA
Authorized Official - Middle Name:
Authorized Official - Last Name:VAUGHN
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:602-606-2658
Mailing Address - Street 1:4045 E BELL RD
Mailing Address - Street 2:STE 111
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-2236
Mailing Address - Country:US
Mailing Address - Phone:602-606-2658
Mailing Address - Fax:602-428-7003
Practice Address - Street 1:4045 E BELL RD
Practice Address - Street 2:STE 111
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-2236
Practice Address - Country:US
Practice Address - Phone:602-606-2658
Practice Address - Fax:602-428-7003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-08
Last Update Date:2016-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000OtherUNKNOWN