Healthcare Provider Details

I. General information

NPI: 1568697340
Provider Name (Legal Business Name): RICHARD MARK WODKA M.DIV.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2009
Last Update Date: 05/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1790 N MASTICK WAY SUITE D
NOGALES AZ
85621-1135
US

IV. Provider business mailing address

1790 N MASTICK WAY SUITE D
NOGALES AZ
85621-1135
US

V. Phone/Fax

Practice location:
  • Phone: 520-223-6910
  • Fax: 520-281-3548
Mailing address:
  • Phone: 520-223-6910
  • Fax: 520-281-3548

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: