MEDICARE: DR. MYLANIE C. FACELO D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	R73583	AZ
2	207Q00000X	Family Medicine Physician	0116028424	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	R73583	OTHER	AZ	TRAINING PERMIT

General Provider Information

NPI Number	:	1639433691
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MYLANIE C. FACELO D.O.

Provider Business Mailing Address
First Line	:	3501 E SPEEDWAY BLVD STE 300
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85716-3928
Country	:	US
Telephone Number	:	520-833-5171
Fax Number	:

Provider Business Practice Location Address
First Line	:	5555 E RIVER RD # 219
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85750-1949
Country	:	US
Telephone Number	:	520-314-4275
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/25/2012
Last Update Date	:	09/20/2018

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