Basic Information
Provider Information
NPI: 1417597857
EntityType: 2
ReplacementNPI:  
OrganizationName: MD24 SAFE HARBOR MI, LLC.
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Mailing Information
Address1: 14780 W MOUNTAIN VIEW BLVD STE 110
Address2:  
City: SURPRISE
State: AZ
PostalCode: 853747280
CountryCode: US
TelephoneNumber: 6233747774
FaxNumber: 8559591911
Practice Location
Address1: 14780 W MOUNTAIN VIEW BLVD STE 110
Address2:  
City: SURPRISE
State: AZ
PostalCode: 853747280
CountryCode: US
TelephoneNumber: 6233747774
FaxNumber: 8559591911
Other Information
ProviderEnumerationDate: 01/14/2020
LastUpdateDate: 01/14/2020
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AuthorizedOfficialLastName: NGUYEN
AuthorizedOfficialFirstName: LINH
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AuthorizedOfficialTitleorPosition: CEO
AuthorizedOfficialTelephone: 6233747774
IsSoleProprietor:  
IsOrganizationSubpart: N
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NPICertificationDate: 01/14/2020

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207Q00000X  Y193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansFamily Medicine 

ID Information
IDTypeStateIssuerDescription
1158542505AZ MEDICAID


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