Healthcare Provider Details

I. General information

NPI: 1659708287
Provider Name (Legal Business Name): MR. VICENTE O. ENCISO III
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2013
Last Update Date: 09/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8611 N 67TH AVE
GLENDALE AZ
85302-4351
US

IV. Provider business mailing address

11721 W JEFFERSON ST
AVONDALE AZ
85323-1195
US

V. Phone/Fax

Practice location:
  • Phone: 623-939-9475
  • Fax:
Mailing address:
  • Phone: 623-313-4655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number5589A
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: