Provider Demographics
NPI:1710381306
Name:MESA HEALTH AND WELLNESS CENTER
Entity Type:Organization
Organization Name:MESA HEALTH AND WELLNESS CENTER
Other - Org Name:ONSITE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:MR
Authorized Official - First Name:DARCE
Authorized Official - Middle Name:
Authorized Official - Last Name:LATSIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-441-1002
Mailing Address - Street 1:560 S 300 E STE 275
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111-3586
Mailing Address - Country:US
Mailing Address - Phone:801-441-1002
Mailing Address - Fax:
Practice Address - Street 1:1121 S GILBERT RD
Practice Address - Street 2:SUITE 101
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-5235
Practice Address - Country:US
Practice Address - Phone:480-644-9355
Practice Address - Fax:480-644-2288
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-10
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4199207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty