=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265740278
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HENRY W. FLOREZ
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/24/2010
-----------------------------------------------------
Last Update Date | 09/24/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2730 S AVENUE B
-----------------------------------------------------
City | YUMA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85364
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-344-9166
-----------------------------------------------------
Fax | 928-344-9168
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2730 S AVENUE B
-----------------------------------------------------
City | YUMA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85364-6903
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-344-9166
-----------------------------------------------------
Fax | 928-344-9168
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. HENRY WILLIAM FLOREZ
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 928-344-9166
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | 4724
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------