Healthcare Provider Details

I. General information

NPI: 1578374948
Provider Name (Legal Business Name): FATTY LIVER CLINIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2025
Last Update Date: 01/15/2025
Certification Date: 01/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3238 E SPEEDWAY BLVD
TUCSON AZ
85716-3934
US

IV. Provider business mailing address

3232 E SPEEDWAY BLVD
TUCSON AZ
85716-3934
US

V. Phone/Fax

Practice location:
  • Phone: 515-822-5585
  • Fax: 520-445-7727
Mailing address:
  • Phone: 515-822-5585
  • Fax: 520-445-7727

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0100X
TaxonomyGastroenterology Registered Nurse
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QI0500X
TaxonomyInfusion Therapy Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SHAHID HABIB
Title or Position: OWNER
Credential: MD
Phone: 515-822-5585