Healthcare Provider Details

I. General information

NPI: 1487253860
Provider Name (Legal Business Name): RONALD JINGCO CALAGUAS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2020
Last Update Date: 10/18/2020
Certification Date: 10/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2432 W PORTOBELLO AVE
MESA AZ
85202-7871
US

IV. Provider business mailing address

2432 W PORTOBELLO AVE
MESA AZ
85202-7871
US

V. Phone/Fax

Practice location:
  • Phone: 480-793-7971
  • Fax: 480-793-7971
Mailing address:
  • Phone: 480-793-7971
  • Fax: 480-793-7971

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberAL11467H
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: