Basic Information
| Provider Information | |||||||||
| NPI: | 1316468333 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MESA OUTPATIENT TREATMENT CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4540 E BASELINE RD STE 119 | ||||||||
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| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852064617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4802728944 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4540 E BASELINE RD STE 119 | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4802728944 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | BUCKNER | ||||||||
| AuthorizedOfficialFirstName: | JEREMY | ||||||||
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| AuthorizedOfficialTitleorPosition: | MBR | ||||||||
| AuthorizedOfficialTelephone: | 4802728944 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.