Healthcare Provider Details

I. General information

NPI: 1629004296
Provider Name (Legal Business Name): VICTOR EMILE PARIC III
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2006
Last Update Date: 11/21/2023
Certification Date: 11/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13395 N MARANA MAIN ST BLDG B
MARANA AZ
85653-7008
US

IV. Provider business mailing address

PO BOX 188
MARANA AZ
85653-0188
US

V. Phone/Fax

Practice location:
  • Phone: 520-682-1091
  • Fax: 520-682-4132
Mailing address:
  • Phone: 520-682-1091
  • Fax: 520-682-4132

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLISAC - 11630
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: