Healthcare Provider Details

I. General information

NPI: 1639473143
Provider Name (Legal Business Name): DAMIAN PLUES RD, CDE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/28/2010
Last Update Date: 12/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

483 W. SEED FARM ROAD
SACATON AZ
85147
US

IV. Provider business mailing address

15963 W YAVAPAI ST
GOODYEAR AZ
85338-9496
US

V. Phone/Fax

Practice location:
  • Phone: 602-271-7940
  • Fax:
Mailing address:
  • Phone: 623-217-6576
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number2011-0505
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number964240
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: