Healthcare Provider Details

I. General information

NPI: 1912469453
Provider Name (Legal Business Name): LOUIS BEDOYA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2019
Last Update Date: 04/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33727 S COLONY DR
RED ROCK AZ
85145-5044
US

IV. Provider business mailing address

33727 S COLONY DR
RED ROCK AZ
85145-5044
US

V. Phone/Fax

Practice location:
  • Phone: 520-404-2232
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code385HR2055X
TaxonomyChild Mental Illness Respite Care
License Number7173970
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: