Healthcare Provider Details

I. General information

NPI: 1427388297
Provider Name (Legal Business Name): SAGUARC PEDIATRICS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2009
Last Update Date: 12/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4530 E. RAY RD STE 130
PHOENIX AZ
85044
US

IV. Provider business mailing address

4530 E. RAY RD STE 130
PHOENIX AZ
85044
US

V. Phone/Fax

Practice location:
  • Phone: 480-783-8960
  • Fax: 780-783-8967
Mailing address:
  • Phone: 480-783-8960
  • Fax: 780-783-8967

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number32674
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number24143
License Number StateAZ

VIII. Authorized Official

Name: DWAYNE MICHAEL ST. JACQUES
Title or Position: OWNER
Credential: MD
Phone: 480-783-8960