Basic Information
| Provider Information | |||||||||
| NPI: | 1801470885 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MA IOM, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 42057 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850802057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024822282 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3329 E BELL RD STE A2-A5 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850322756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024822282 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2021 | ||||||||
| LastUpdateDate: | 05/06/2021 | ||||||||
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| AuthorizedOfficialLastName: | WAYCHOFF | ||||||||
| AuthorizedOfficialFirstName: | PIERCE | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6024822282 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
No ID Information.