Healthcare Provider Details

I. General information

NPI: 1619338167
Provider Name (Legal Business Name): BOYS AND GIRLS PEDIATRIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2016
Last Update Date: 03/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2727 W BASELINE RD SUITE 11
TEMPE AZ
85283-1067
US

IV. Provider business mailing address

2727 W BASELINE RD SUITE 11
TEMPE AZ
85283-1067
US

V. Phone/Fax

Practice location:
  • Phone: 602-714-5064
  • Fax: 602-714-5314
Mailing address:
  • Phone: 602-714-5064
  • Fax: 602-714-5314

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: ENRIQUE M CIFUENTES
Title or Position: MEDICAL DIRECTOR
Credential:
Phone: 602-714-5064