Healthcare Provider Details

I. General information

NPI: 1023365665
Provider Name (Legal Business Name): BART TRUJILLO RT(R)
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2012
Last Update Date: 08/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12033 AGENCY RD
PARKER AZ
85344-7718
US

IV. Provider business mailing address

12033 AGENCY RD
PARKER AZ
85344-7718
US

V. Phone/Fax

Practice location:
  • Phone: 928-669-3380
  • Fax:
Mailing address:
  • Phone: 928-669-3380
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2471C3402X
TaxonomyRadiography Radiologic Technologist
License Number423717
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: