MEDICARE: MR. JUAN M VASQUEZ NONE

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	320800000X	Mental Illness Community Based Residential Treatment Facility	2433	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2433	OTHER	AZ	BEHAVIORAL HEALTH NUMBER

General Provider Information

NPI Number	:	1912046566
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JUAN M VASQUEZ NONE

Provider Business Mailing Address
First Line	:	9264 S. WILT BANK RD.
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85735
Country	:	US
Telephone Number	:	520-440-0630
Fax Number	:	520-319-5491

Provider Business Practice Location Address
First Line	:	9264 S. WILT BANK ROAD
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85735
Country	:	US
Telephone Number	:	520-440-0630
Fax Number	:	520-319-5491

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

Provider Enumeration Date	:	02/06/2007
Last Update Date	:	07/08/2007

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