Healthcare Provider Details

I. General information

NPI: 1982742813
Provider Name (Legal Business Name): JIMMY CREDO RRT-NPS, RPFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

167 N. MAIN STREET
TUBA CITY AZ
86045
US

IV. Provider business mailing address

3705 N STEVES BLVD
FLAGSTAFF AZ
86004-6842
US

V. Phone/Fax

Practice location:
  • Phone: 928-283-2596
  • Fax:
Mailing address:
  • Phone: 928-714-0746
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2279P1006X
TaxonomyPulmonary Function Technologist Registered Respiratory Therapist
License Number5409
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: