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General NPI Number Information
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NPI Number | 1205173150
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Entity Type | Organization
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Legal Business Name | LUREA INMAN
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Dates
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Enumeration Date | 01/12/2013
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Last Update Date | 01/12/2013
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Provider Practice Location Address
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Address Line | 18610 E RAVEN DR
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City | QUEEN CREEK
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State | AZ
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Zip | 85142-5542
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Country | US
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Telephone | 480-747-4143
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Fax |
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Provider Business Mailing Address
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Address Line | 18658 E RAVEN DR
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City | QUEEN CREEK
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State | AZ
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Zip | 85142-5542
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Country | US
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Telephone | 480-747-4143
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Fax |
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Authorized Official
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Title or Position | OCCUPATIONAL THERAPY ASSISTANT
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Name | MRS. LUREA SHELLY INMAN
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Credential | COTA/L
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Telephone | 480-747-4143
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QX0100X
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Taxonomy Name | Occupational Medicine Clinic/Center
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License Number | 4979
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License Number State | AZ
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