# MIRAGE MEDICAL LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1609206549
- **Authorized official:** DR. JEREMY R BUCKNER D.C. (OWNER)
- **Authorized official phone:** (602) 421-2730

## Contact information

- **Practice address:** 10046 N METRO PKWY W, SUITE 115, PHOENIX, AZ 85051-1437
- **Practice address phone:** (602) 674-5515
- **Practice address fax:** (602) 674-3029
- **Mailing address:** 1001 E WARNER RD, SUITE 107, TEMPE, AZ 85284-3224
- **Mailing address phone:** (480) 264-3744
- **Mailing address fax:** (480) 264-2075

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 2081P2900X | Pain Medicine (Physical Medicine & Rehabilitation) Physician | 5988 | AZ | Yes |
| 363LF0000X | Family Nurse Practitioner | AP4986 | AZ | — |
| 364SF0001X | Family Health Clinical Nurse Specialist | AP2828 | AZ | — |

## Other

- **Enumeration date:** 11/13/2013
- **Last updated:** 11/13/2013