Healthcare Provider Details

I. General information

NPI: 1649311853
Provider Name (Legal Business Name): ERIC LAUER FOSTER PARENT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2702 N 3RD ST
PHOENIX AZ
85004-1130
US

IV. Provider business mailing address

16640 S 25TH ST
PHOENIX AZ
85048-8202
US

V. Phone/Fax

Practice location:
  • Phone: 602-279-1427
  • Fax:
Mailing address:
  • Phone: 480-219-4809
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: