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Registrant NPI Number: 1780679571

Individual Registrant:
Gender: M
Sole Proprietor

Location and contact information for practice:
Tel: 520-494-8077  Fax: 520-494-8081

Contact information for business:
Tel: 520-494-8077  Fax: 502-494-8081

Registration Information:
NPI: 1780679571
Entity Type: Individual

Specialty information:

PrimaryCodeCategory/DescriptionStateLicense Number
Y175F00000XOther Service Providers

Legacy codes, insurance codes and state license numbers:



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