Basic Information
| Provider Information | |||||||||
| NPI: | 1689035479 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MERIDIAN THERAPEUTICS CLINIC LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4045 E BELL RD | ||||||||
| Address2: | STE 111 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850322236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6026062658 | ||||||||
| FaxNumber: | 6024287003 | ||||||||
| Practice Location | |||||||||
| Address1: | 4045 E BELL RD | ||||||||
| Address2: | STE 111 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850322236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6026062658 | ||||||||
| FaxNumber: | 6024287003 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2016 | ||||||||
| LastUpdateDate: | 03/08/2016 | ||||||||
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| AuthorizedOfficialLastName: | VAUGHN | ||||||||
| AuthorizedOfficialFirstName: | KIMARA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/ NURSE PRACTITIONER | ||||||||
| AuthorizedOfficialTelephone: | 6026062658 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | NP | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 000000 | 01 | UNKNOWN | OTHER |