Provider Demographics
NPI:1972249019
Name:FENIX MEDICAL LLC
Entity Type:Organization
Organization Name:FENIX MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:FAIR
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:480-788-0399
Mailing Address - Street 1:18477 S 186TH WAY STE 102
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85142-9620
Mailing Address - Country:US
Mailing Address - Phone:480-788-0399
Mailing Address - Fax:
Practice Address - Street 1:18477 S 186TH WAY STE 102
Practice Address - Street 2:
Practice Address - City:QUEEN CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85142-9620
Practice Address - Country:US
Practice Address - Phone:480-788-0399
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-11
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
1OtherN/A