Healthcare Provider Details

I. General information

NPI: 1497821920
Provider Name (Legal Business Name): RANDY DANIEL FLORES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/27/2006
Last Update Date: 07/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

188 W IVEY RD
HUACHUCA CITY AZ
85616-8227
US

IV. Provider business mailing address

188 W IVEY RD
HUACHUCA CITY AZ
85616-8227
US

V. Phone/Fax

Practice location:
  • Phone: 520-456-1416
  • Fax:
Mailing address:
  • Phone: 520-456-1416
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code385HR2055X
TaxonomyChild Mental Illness Respite Care
License Number
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: