MEDICARE: FRED MIRANDA

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	385HR2055X	Child Mental Illness Respite Care	3856	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	AHCCCS	OTHER	AZ	729725

General Provider Information

NPI Number	:	1669546610
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FRED MIRANDA

Provider Business Mailing Address
First Line	:	4044 W HADLEY ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85009-5310
Country	:	US
Telephone Number	:	602-272-1213
Fax Number	:

Provider Business Practice Location Address
First Line	:	4044 W HADLEY ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85009-5310
Country	:	US
Telephone Number	:	602-272-1213
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/20/2006
Last Update Date	:	07/08/2007

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Directions to “ FRED MIRANDA ” Practice Location

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