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General NPI Number Information
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NPI Number | 1295131712
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Entity Type | Organization
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Legal Business Name | INTEGRA HOME DOCTORS, INC.
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Dates
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Enumeration Date | 11/11/2014
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Last Update Date | 05/23/2016
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Provider Practice Location Address
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Address Line | 16165 N 83RD AVE SUITE 200
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City | PEORIA
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State | AZ
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Zip | 85382-5816
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Country | US
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Telephone | 623-888-3014
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Fax |
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Provider Business Mailing Address
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Address Line | 16165 N 83RD AVE SUITE 200
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City | PEORIA
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State | AZ
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Zip | 85382-5816
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Country | US
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Telephone | 623-888-3014
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. GLENN LEONG MANGUERRA
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Credential |
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Telephone | 773-791-9340
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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License Number State |
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