MEDICARE: JESUS DUARTE

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	3887	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	738148	OTHER	AZ	AHCCCS ID

General Provider Information

NPI Number	:	1841358231
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESUS DUARTE

Provider Business Mailing Address
First Line	:	PO BOX 50224
Second Line	:
City	:	PARKS
State	:	AZ
Zip	:	86018-0224
Country	:	US
Telephone Number	:	928-600-5544
Fax Number	:

Provider Business Practice Location Address
First Line	:	291 N. STEVENS LN.
Second Line	:	LOT 13
City	:	PARKS
State	:	AZ
Zip	:	86018
Country	:	US
Telephone Number	:	928-600-5544
Fax Number	:

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

Provider Enumeration Date	:	12/05/2006
Last Update Date	:	07/08/2007

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Directions to “ JESUS DUARTE ” Practice Location

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