Healthcare Provider Details

I. General information

NPI: 1003350430
Provider Name (Legal Business Name): GHAIDAA KOBEISSI RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2016
Last Update Date: 09/13/2021
Certification Date: 09/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10350 E DREXEL RD UNIT 110
TUCSON AZ
85747-9409
US

IV. Provider business mailing address

5301 E GRANT RD
TUCSON AZ
85712-2805
US

V. Phone/Fax

Practice location:
  • Phone: 520-324-1727
  • Fax: 520-324-1700
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86063787
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: