1124026307 NPI number — TRACY B PERUCH DC

Table of content: TRACY B PERUCH DC (NPI 1124026307)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124026307 NPI number — TRACY B PERUCH DC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PERUCH
Provider First Name:
TRACY
Provider Middle Name:
B
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DC
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:
1124026307
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/06/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6770 W DEER VALLEY RD
Provider Second Line Business Mailing Address:
#B102
Provider Business Mailing Address City Name:
GLENDALE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85310-5956
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-362-1950
Provider Business Mailing Address Fax Number:
623-572-2741

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6770 W DEER VALLEY RD
Provider Second Line Business Practice Location Address:
#B102
Provider Business Practice Location Address City Name:
GLENDALE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85310-5956
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-362-1950
Provider Business Practice Location Address Fax Number:
623-572-2741
Provider Enumeration Date:
07/12/2005

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: 111N00000X , with the licence number:  5710 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 175F00000X , with the licence number: 09-1105 , 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)

  • Identifier: 1Z5304 . This is a "HEALTH NET" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: AZ0940160 . This is a "BLUE CROSS BLUE SHEILD" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com