Healthcare Provider Details

I. General information

NPI: 1073970133
Provider Name (Legal Business Name): MEDIFAST TUCSON COM INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/20/2016
Last Update Date: 01/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5350 E ERICKSON DR
TUCSON AZ
85712-2822
US

IV. Provider business mailing address

PO BOX 14377
TUCSON AZ
85732-4377
US

V. Phone/Fax

Practice location:
  • Phone: 520-733-2250
  • Fax: 520-733-2270
Mailing address:
  • Phone: 520-733-2250
  • Fax: 520-733-2270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State

VIII. Authorized Official

Name: BRAD T MANNY
Title or Position: PRESIDENT
Credential: MD
Phone: 520-733-2250