Healthcare Provider Details

I. General information

NPI: 1386088128
Provider Name (Legal Business Name): CLIFTON JAMAR PREMO RRT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2013
Last Update Date: 04/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13517 W GLENDALE AVE APT 1135
GLENDALE AZ
85307-2010
US

IV. Provider business mailing address

13517 W GLENDALE AVE APT 1135
GLENDALE AZ
85307-2010
US

V. Phone/Fax

Practice location:
  • Phone: 602-832-2614
  • Fax:
Mailing address:
  • Phone: 602-832-2614
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License Number010733
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: