Healthcare Provider Details

I. General information

NPI: 1275794471
Provider Name (Legal Business Name): CHARLES ESQUIVEL09
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2008
Last Update Date: 06/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 W MEDICAL ST
TUCSON AZ
85704-1133
US

IV. Provider business mailing address

1919 W MEDICAL ST
TUCSON AZ
85704-1133
US

V. Phone/Fax

Practice location:
  • Phone: 520-297-8311
  • Fax: 520-219-7249
Mailing address:
  • Phone: 520-297-8311
  • Fax: 520-219-7249

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number1731
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: