Healthcare Provider Details

I. General information

NPI: 1902274145
Provider Name (Legal Business Name): MR. RICARDO HERNANDEZ JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2015
Last Update Date: 09/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3462 E CHARLESTON AVE
PHOENIX AZ
85032-1219
US

IV. Provider business mailing address

3462 E CHARLESTON AVE
PHOENIX AZ
85032-1219
US

V. Phone/Fax

Practice location:
  • Phone: 602-810-1666
  • Fax:
Mailing address:
  • Phone: 602-810-1666
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RM2200X
TaxonomyMedical Laboratory Technician
License Number25444944
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: