Provider Demographics
NPI:1942506019
Name:MEHIC, MIRNES
Entity Type:Individual
Prefix:
First Name:MIRNES
Middle Name:
Last Name:MEHIC
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2018 E. WAGONER RD.
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85022
Mailing Address - Country:US
Mailing Address - Phone:480-720-4591
Mailing Address - Fax:602-788-2246
Practice Address - Street 1:2018 E. WAGONER RD.
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85022
Practice Address - Country:US
Practice Address - Phone:480-720-4591
Practice Address - Fax:602-788-2246
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-07
Last Update Date:2011-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL7900H310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ310400000XOtherAHCCCS