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General NPI Number Information
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NPI Number | 1326310442
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Entity Type | Organization
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Legal Business Name | MARIGOLD ENTERPRISE
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Dates
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Enumeration Date | 02/05/2012
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Last Update Date | 02/05/2012
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Provider Practice Location Address
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Address Line | 500 N LENZNER AVE B-9
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City | SIERRA VISTA
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State | AZ
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Zip | 85635-2167
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Country | US
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Telephone | 520-236-7692
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 910
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City | HEREFORD
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State | AZ
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Zip | 85615-0910
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Country | US
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Telephone | 520-236-7692
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Fax |
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Authorized Official
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Title or Position | OCCUPATIONAL THERAPIST
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Name | MS. VICTORIA L HARRIS
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Credential | OTR
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Telephone | 520-236-7692
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305S00000X
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Taxonomy Name | Point of Service
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License Number | 0651
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License Number State | AZ
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