Healthcare Provider Details

I. General information

NPI: 1497021679
Provider Name (Legal Business Name): TEQUA MED-PEDS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2012
Last Update Date: 04/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 W RIVERSIDE DR
PARKER AZ
85344-5119
US

IV. Provider business mailing address

3269 MARICOPA AVE SUITE 114-239
LAKE HAVASU CITY AZ
86406-8593
US

V. Phone/Fax

Practice location:
  • Phone: 928-669-5550
  • Fax:
Mailing address:
  • Phone: 928-669-5550
  • Fax: 928-669-0061

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number5436
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number5436
License Number StateAZ

VIII. Authorized Official

Name: TEQUA SALEHI-RAD
Title or Position: OWNER/MEMBER
Credential: D.O.
Phone: 928-669-5550