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General NPI Number Information
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NPI Number | 1649457193
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Entity Type | Organization
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Legal Business Name | TINY TOTS PEDIATRICS LLC
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Dates
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Enumeration Date | 01/28/2008
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Last Update Date | 02/08/2012
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Provider Practice Location Address
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Address Line | 2020 SILVERCREEK ROAD SUITE 114 BULIDING A
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City | BULLHEAD CITY
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State | AZ
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Zip | 86442
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Country | US
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Telephone | 928-763-7020
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Fax | 928-763-7050
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Provider Business Mailing Address
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Address Line | PO BOX 23245
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City | BULLHEAD CITY
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State | AZ
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Zip | 86439-3245
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Country | US
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Telephone | 928-763-7020
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. MARYLOU REYES
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Credential | M.D.
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Telephone | 928-763-7020
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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 | 28997
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License Number State | AZ
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