Provider Demographics
NPI:1487784450
Name:MOLLEN IMMUNIZATION CLINICS OF NORTH AMERICA, INC.
Entity type:Organization
Organization Name:MOLLEN IMMUNIZATION CLINICS OF NORTH AMERICA, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SR. VICE PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:WATTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-264-9806
Mailing Address - Street 1:4602 N 16TH ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-5189
Mailing Address - Country:US
Mailing Address - Phone:602-264-9806
Mailing Address - Fax:602-264-9846
Practice Address - Street 1:4602 N 16TH ST
Practice Address - Street 2:SUITE 200
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-5189
Practice Address - Country:US
Practice Address - Phone:602-264-9806
Practice Address - Fax:602-264-9846
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZFL115Medicare PIN