=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669250205
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RICHARD RAYMOND FLORES PT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/15/2023
-----------------------------------------------------
Last Update Date | 09/15/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3507 S MERCY RD STE 105
-----------------------------------------------------
City | GILBERT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85297-0441
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-710-8154
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4221 E TANGLEWOOD DR
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85048-7415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-710-8154
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2081S0010X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Physical Medicine & Rehabilitation) Physician
-----------------------------------------------------
License Number | 33219
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------