Healthcare Provider Details

I. General information

NPI: 1467620567
Provider Name (Legal Business Name): MR. RICHARD C. ACOSTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2008
Last Update Date: 03/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 E 15TH ST
DOUGLAS AZ
85607-1731
US

IV. Provider business mailing address

1500 E 15TH ST
DOUGLAS AZ
85607-1731
US

V. Phone/Fax

Practice location:
  • Phone: 520-364-3462
  • Fax: 520-805-4171
Mailing address:
  • Phone: 520-364-3462
  • Fax: 520-805-4171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: