Basic Information
| Provider Information | |||||||||
| NPI: | 1184998908 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | QUICK CARE EAST VALLEY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7233 E BASELINE RD | ||||||||
| Address2: | STE 127 | ||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852095007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806994555 | ||||||||
| FaxNumber: | 4806993033 | ||||||||
| Practice Location | |||||||||
| Address1: | 7233 E BASELINE RD | ||||||||
| Address2: | STE 127 | ||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852095007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806994555 | ||||||||
| FaxNumber: | 4806993033 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2012 | ||||||||
| LastUpdateDate: | 02/24/2012 | ||||||||
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| AuthorizedOfficialLastName: | ALLEN | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4806994555 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | 36540 | AZ | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
ID Information
| ID | Type | State | Issuer | Description | 1952380925 | 01 | AZ | NPI | OTHER | 569897 | 05 | AZ | MEDICAID | 119260-1215960638 | 01 | AZ | MEDICARE PTAN | OTHER |