MEDICARE: EDWARD GRIJALVA SR.

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	11811	AZ

General Provider Information

NPI Number	:	1679932867
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EDWARD GRIJALVA SR.

Provider Business Mailing Address
First Line	:	2601 N CAMPBELL AVE STE 108
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85719-3164
Country	:	US
Telephone Number	:	520-623-6015
Fax Number	:	520-623-4590

Provider Business Practice Location Address
First Line	:	2601 N CAMPBELL AVE STE 108
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85719-3164
Country	:	US
Telephone Number	:	520-623-6015
Fax Number	:	520-623-4590

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

Provider Enumeration Date	:	02/16/2016
Last Update Date	:	02/16/2016

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Directions to “ EDWARD GRIJALVA SR. ” Practice Location

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