Healthcare Provider Details

I. General information

NPI: 1306481247
Provider Name (Legal Business Name): DYMPHNA I MEDINA LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2019
Last Update Date: 11/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 W CONTINENTAL RD STE 130A
GREEN VALLEY AZ
85622-3546
US

IV. Provider business mailing address

5264 W GOLDEN VISTA WAY
TUCSON AZ
85713-6358
US

V. Phone/Fax

Practice location:
  • Phone: 520-906-8358
  • Fax:
Mailing address:
  • Phone: 520-780-2015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225000000X
TaxonomyOrthotic Fitter
License Number18456
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number18456
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: