Facts
- Status
- A
- Credential
- MLD, CLT, LMT
- Type
- Individual
- Enumeration date
- 2026-06-01
- Last updated
- 2026-06-01
Specialties
Licenses
- License AZ
- MT-19662
Location
- Practice location
- 6282 W HARDSCRABBLE MESA RD
- City
- PINE AZ
- Postal code
- 855445240
- Phone
- 480-205-0311
Medicare
- PECOS
- No PECOS enrollment row matched this NPI.
LEIE
The OIG NPI list is not in this build yet. Confirm on OIG's search.
Nearby
Search this city from the state hub for other records in the public registry.
Removal request
Public data from NPPES and CMS. Not a credentialing determination.