Healthcare Provider Details

I. General information

NPI: 1467658948
Provider Name (Legal Business Name): SALLY ANN TEODORO MCD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13934 N 59TH AVE
GLENDALE AZ
85306-4167
US

IV. Provider business mailing address

7223 W WILLOW AVE
PEORIA AZ
85381-6055
US

V. Phone/Fax

Practice location:
  • Phone: 602-866-0147
  • Fax:
Mailing address:
  • Phone: 623-486-9567
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number720
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: