=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447881933
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MILAGROS FAMILY HEALTHCARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2020
-----------------------------------------------------
Last Update Date | 03/08/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5422 S 12TH AVE
-----------------------------------------------------
City | TUCSON
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85706-3284
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-900-3667
-----------------------------------------------------
Fax | 520-337-3343
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 43100
-----------------------------------------------------
City | TUCSON
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85733-3100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-900-3667
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | AXSUNN RAMIREZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 520-900-3667
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------