Provider Demographics
NPI:1538565049
Name:UCXTRA UMBRELLA, LLC
Entity type:Organization
Organization Name:UCXTRA UMBRELLA, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:M
Authorized Official - Last Name:PANDURO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-663-2432
Mailing Address - Street 1:1250 S CLEARVIEW AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85209-3378
Mailing Address - Country:US
Mailing Address - Phone:480-988-9108
Mailing Address - Fax:480-813-4460
Practice Address - Street 1:6702 W BETHANY HOME RD
Practice Address - Street 2:SUITE 13, 14 & 15
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85303-4402
Practice Address - Country:US
Practice Address - Phone:623-435-7000
Practice Address - Fax:623-435-3947
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-10
Last Update Date:2015-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1518952365261QE0002X
261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No261QE0002XAmbulatory Health Care FacilitiesClinic/CenterEmergency Care