Healthcare Provider Details

I. General information

NPI: 1457826224
Provider Name (Legal Business Name): JAIME EMMANUEL VALLES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2018
Last Update Date: 08/19/2024
Certification Date: 08/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1233 N MAIN ST STE 1A
SAN LUIS AZ
85336-0663
US

IV. Provider business mailing address

PO BOX 617
SOMERTON AZ
85350-0617
US

V. Phone/Fax

Practice location:
  • Phone: 928-550-5514
  • Fax:
Mailing address:
  • Phone: 928-315-7910
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN158684
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number219043
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: