Healthcare Provider Details

I. General information

NPI: 1578570081
Provider Name (Legal Business Name): SERGIO I MACIAS PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 10/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1233 N MAIN STREET SUITE 10, 11 & 12
SAN LUIS AZ
85349-9999
US

IV. Provider business mailing address

PO BOX 5841
YUMA AZ
85366-2490
US

V. Phone/Fax

Practice location:
  • Phone: 928-722-6050
  • Fax: 928-722-6094
Mailing address:
  • Phone: 928-343-7911
  • Fax: 928-343-9528

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberC001071
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number4229
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: