Healthcare Provider Details

I. General information

NPI: 1174766778
Provider Name (Legal Business Name): YURI A TALALAEV
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2009
Last Update Date: 12/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 W CONTINENTAL RD
GREEN VALLEY AZ
85614-3551
US

IV. Provider business mailing address

450 W CONTINENTAL RD
GREEN VALLEY AZ
85614-3551
US

V. Phone/Fax

Practice location:
  • Phone: 520-393-0898
  • Fax:
Mailing address:
  • Phone: 520-393-0898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number28484
License Number StateAZ

VIII. Authorized Official

Name: DR. YURI TALALAEV
Title or Position: DOCTOR
Credential:
Phone: 520-393-0898