1063824274 NPI number — MR. MICHAEL A VALENZUELA SR. SA-C

Table of content: MR. MICHAEL A VALENZUELA SR. SA-C (NPI 1063824274)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063824274 NPI number — MR. MICHAEL A VALENZUELA SR. SA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VALENZUELA
Provider First Name:
MICHAEL
Provider Middle Name:
A
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
SR.
Provider Credential Text:
SA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063824274
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/08/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1830 E BROADWAY BLVD
Provider Second Line Business Mailing Address:
PMB 124-114
Provider Business Mailing Address City Name:
TUCSON
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85719-5966
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-349-4979
Provider Business Mailing Address Fax Number:
520-647-9174

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1830 E BROADWAY BLVD
Provider Second Line Business Practice Location Address:
PMB 124-114
Provider Business Practice Location Address City Name:
TUCSON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85719-5966
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-349-4979
Provider Business Practice Location Address Fax Number:
520-647-9174
Provider Enumeration Date:
05/21/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 246ZC0007X , with the licence number:  14-258 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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