=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245501188
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAN PEDRO HEALTH PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2012
-----------------------------------------------------
Last Update Date | 04/30/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4151 LA LINDA WAY SUITE # 102
-----------------------------------------------------
City | SIERRA VISTA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85635-4600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-515-9610
-----------------------------------------------------
Fax | 520-515-0031
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4151 LA LINDA WAY SUITE # 102
-----------------------------------------------------
City | SIERRA VISTA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85635-4600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-515-9610
-----------------------------------------------------
Fax | 520-515-0031
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | DR. JAMES PHILLIP REED
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 520-515-9610
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number | 2845
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------