Healthcare Provider Details

I. General information

NPI: 1528499514
Provider Name (Legal Business Name): CLYDE IRONS JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2013
Last Update Date: 12/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 ROSE LN
WICKENBURG AZ
85390-1447
US

IV. Provider business mailing address

10825 N 43RD ST
PHOENIX AZ
85028-3505
US

V. Phone/Fax

Practice location:
  • Phone: 928-684-4368
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2279G1100X
TaxonomyGeneral Care Registered Respiratory Therapist
License Number010739
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: