Healthcare Provider Details

I. General information

NPI: 1003132705
Provider Name (Legal Business Name): MARK D TIBBLES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2010
Last Update Date: 04/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2045 S 14TH AVE #73
YUMA AZ
85364-6275
US

IV. Provider business mailing address

2045 S 14TH AVE #73
YUMA AZ
85364-6275
US

V. Phone/Fax

Practice location:
  • Phone: 928-581-3036
  • Fax:
Mailing address:
  • Phone: 928-581-3036
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberHAD5886
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: