Provider Demographics
NPI:1972134054
Name:FALA MEDICAL CLINIC PLLC
Entity type:Organization
Organization Name:FALA MEDICAL CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISITRATOR
Authorized Official - Prefix:
Authorized Official - First Name:FRESCHTA
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRZAKHEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-258-8264
Mailing Address - Street 1:14749 W MOUNTAIN VIEW BLVD STE 138
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-2704
Mailing Address - Country:US
Mailing Address - Phone:623-738-0440
Mailing Address - Fax:480-374-8051
Practice Address - Street 1:14749 W MOUNTAIN VIEW BLVD STE 138
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-2704
Practice Address - Country:US
Practice Address - Phone:623-738-0440
Practice Address - Fax:480-374-8051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-28
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ546663Medicaid