Basic Information
| Provider Information | |||||||||
| NPI: | 1184111692 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STATCLINIX PLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | STATCLINIX - LAKESIDE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1151 N GILBERT RD | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852035127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4506824118 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3457 W WHITE MOUNTAIN BLVD | ||||||||
| Address2: | |||||||||
| City: | LAKESIDE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85929 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9283581515 | ||||||||
| FaxNumber: | 9283581517 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2018 | ||||||||
| LastUpdateDate: | 04/19/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | KIMBERLEE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL STAFF COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 4806824118 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | AZ | MEDICAID |