Provider Demographics
NPI:1366170656
Name:MAYNE MEDICAL, LLC
Entity type:Organization
Organization Name:MAYNE MEDICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PA, RENDERING PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:JENNELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:SUAREZ
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:480-688-3321
Mailing Address - Street 1:10645 N TATUM BLVD STE C200464
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-0425
Mailing Address - Country:US
Mailing Address - Phone:480-688-3321
Mailing Address - Fax:480-393-7197
Practice Address - Street 1:4524 N MARYVALE PKWY STE 160
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85031-1739
Practice Address - Country:US
Practice Address - Phone:480-688-3321
Practice Address - Fax:480-393-7197
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-12
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty