MEDICARE: RICHARD LEE AVERITTE JR., PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332900000X	Non-Pharmacy Dispensing Site	34857	AZ

General Provider Information

NPI Number	:	1619428851
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RICHARD LEE AVERITTE JR., PLLC

Provider Business Mailing Address
First Line	:	20401 N 73RD ST
Second Line	:	SUITE 230
City	:	SCOTTSDALE
State	:	AZ
Zip	:	85255-4107
Country	:	US
Telephone Number	:	480-556-0446
Fax Number	:	480-223-6850

Provider Business Practice Location Address
First Line	:	41810 N VENTURE DR
Second Line	:	SUITE D136
City	:	ANTHEM
State	:	AZ
Zip	:	85086-3169
Country	:	US
Telephone Number	:	480-556-0446
Fax Number	:	480-223-6850

Authorized Official
Title or Position	:	CFO
Name	:	MARLIE AVERITTE
Credential	:
Telephone Number	:	480-556-0446

Provider Enumeration Date	:	10/24/2016
Last Update Date	:	10/24/2016

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