Healthcare Provider Details

I. General information

NPI: 1043516610
Provider Name (Legal Business Name): CHARLES DELVON PICKETT IDMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2011
Last Update Date: 08/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7019 N LITCHFIELD AVE LUKE AFB, 56/AMDS
LUKE AFB AZ
85309
US

IV. Provider business mailing address

16240 W PIMA ST
GOODYEAR AZ
85338-7927
US

V. Phone/Fax

Practice location:
  • Phone: 623-856-7527
  • Fax:
Mailing address:
  • Phone: 480-233-5021
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: