| Az Mobile Medical Clinic Llc | |
|
5342 W Western Star Blvd Laveen AZ 85339-4510 | |
| (602) 723-2126 | |
| Not Available |
| Full Name | Az Mobile Medical Clinic Llc |
|---|---|
| Speciality | General Practice |
| Location | 5342 W Western Star Blvd, Laveen, Arizona |
| Authorized Official Name and Position | John Richard Groff (OWNER) |
| Authorized Official Contact | 6027232126 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Az Mobile Medical Clinic Llc 5342 W Western Star Blvd Laveen AZ 85339-4510 Ph: () - | Az Mobile Medical Clinic Llc 5342 W Western Star Blvd Laveen AZ 85339-4510 Ph: (602) 723-2126 |
| NPI Number | 1013766484 |
|---|---|
| Provider Enumeration Date | 05/16/2024 |
| Last Update Date | 05/16/2024 |
| Medicare PECOS PAC ID | 6002350014 |
|---|---|
| Medicare Enrollment ID | O20240702000563 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1013766484 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 208D00000X | General Practice | (* (Not Available)) | Primary |
| Provider Name | Laureen Cota |
|---|---|
| Provider Type | Practitioner - Podiatry |
| Provider Identifiers | NPI Number: 1548275969 PECOS PAC ID: 7416048871 Enrollment ID: I20070814000656 |
| Provider Name | Micah Ruben Ruybalid |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1619695277 PECOS PAC ID: 7911370127 Enrollment ID: I20230308001468 |
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