Healthcare Provider Details

I. General information

NPI: 1831471671
Provider Name (Legal Business Name): TED GREER LASAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2011
Last Update Date: 09/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 N PLAZA DR
APACHE JUNCTION AZ
85120-5501
US

IV. Provider business mailing address

PO BOX 3160
APACHE JUNCTION AZ
85117-4115
US

V. Phone/Fax

Practice location:
  • Phone: 480-983-0065
  • Fax: 481-671-4541
Mailing address:
  • Phone: 480-983-0065
  • Fax: 480-671-4541

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLASAC-13203
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: