Provider Demographics
NPI:1245648088
Name:MLM FAMILY LLC
Entity type:Organization
Organization Name:MLM FAMILY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:LANA
Authorized Official - Middle Name:
Authorized Official - Last Name:KHATIB
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:602-339-3669
Mailing Address - Street 1:2031 E GLENHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85048-8122
Mailing Address - Country:US
Mailing Address - Phone:602-339-3669
Mailing Address - Fax:
Practice Address - Street 1:15410 S MOUNTAIN PKWY
Practice Address - Street 2:SUITE 105
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85044-6691
Practice Address - Country:US
Practice Address - Phone:602-339-3669
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-24
Last Update Date:2014-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5212363AM0700X
AZ42064207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty