Healthcare Provider Details

I. General information

NPI: 1588696298
Provider Name (Legal Business Name): JOHN R OMOHUNDRO ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8701 S HARDY DR
TEMPE AZ
85284-2800
US

IV. Provider business mailing address

8701 S HARDY DR
TEMPE AZ
85284-2800
US

V. Phone/Fax

Practice location:
  • Phone: 602-379-0101
  • Fax: 480-467-1952
Mailing address:
  • Phone: 602-379-0101
  • Fax: 480-467-1952

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number0087
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: