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General NPI Number Information
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NPI Number | 1497021679
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Entity Type | Organization
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Legal Business Name | TEQUA MED-PEDS LLC
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Dates
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Enumeration Date | 04/01/2012
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Last Update Date | 04/01/2012
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Provider Practice Location Address
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Address Line | 601 W RIVERSIDE DR
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City | PARKER
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State | AZ
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Zip | 85344-5119
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Country | US
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Telephone | 928-669-5550
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Fax |
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Provider Business Mailing Address
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Address Line | 3269 MARICOPA AVE SUITE 114-239
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City | LAKE HAVASU CITY
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State | AZ
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Zip | 86406-8593
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Country | US
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Telephone | 928-669-5550
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Fax | 928-669-0061
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Authorized Official
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Title or Position | OWNER/MEMBER
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Name | TEQUA SALEHI-RAD
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Credential | D.O.
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Telephone | 928-669-5550
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 5436
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License Number State | AZ
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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 5436
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License Number State | AZ
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