Healthcare Provider Details

I. General information

NPI: 1356790158
Provider Name (Legal Business Name): BANNER UMC DPEC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2016
Last Update Date: 06/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3950 S COUNTRY CLUB ROAD SUITE 130
TUCSON AZ
85714
US

IV. Provider business mailing address

3950 S COUNTRY CLUB ROAD 130
TUCSON AZ
85714
US

V. Phone/Fax

Practice location:
  • Phone: 520-874-2000
  • Fax: 520-874-4801
Mailing address:
  • Phone: 520-874-2000
  • Fax: 520-874-4801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number942958258
License Number StateAZ

VIII. Authorized Official

Name: MERRI PENDERGRASS
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 520-626-6376