Individual
ABO ALL
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
3907 W PALO VERDE DR, PHOENIX, AZ 85019-1828
(602) 405-5500
Mailing address
3907 W PALO VERDE DR, PHOENIX, AZ 85019-1828
(602) 405-5500
Taxonomy
Speciality
Code
Description
License number
State
343900000X
Non-emergency Medical Transport (VAN)
Primary
D04734495
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
710681
AHCCCS
AZ
Enumeration date
07/06/2012
Last updated
07/06/2012
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