Provider Demographics
NPI:1003225665
Name:VILLALVAZO, JORGE ALBERTO (HAD)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:ALBERTO
Last Name:VILLALVAZO
Suffix:
Gender:M
Credentials:HAD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1989 FRONTAGE RD
Mailing Address - Street 2:
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85635-4698
Mailing Address - Country:US
Mailing Address - Phone:520-458-3383
Mailing Address - Fax:520-458-9623
Practice Address - Street 1:1989 FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-4698
Practice Address - Country:US
Practice Address - Phone:520-458-3383
Practice Address - Fax:520-458-9623
Is Sole Proprietor?:No
Enumeration Date:2014-08-07
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZHAD1906237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist