Healthcare Provider Details

I. General information

NPI: 1306141171
Provider Name (Legal Business Name): CALVIN KEITH BAILEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2011
Last Update Date: 01/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12168 W MIAMI ST
TOLLESON AZ
85353-2741
US

IV. Provider business mailing address

12168 W MIAMI ST
TOLLESON AZ
85353-2741
US

V. Phone/Fax

Practice location:
  • Phone: 309-453-3130
  • Fax:
Mailing address:
  • Phone: 309-453-3130
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number896773
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: