Provider Demographics
NPI:1083064331
Name:APODACA, LUIS
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:
Last Name:APODACA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6251 E 25TH ST
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711-6014
Mailing Address - Country:US
Mailing Address - Phone:520-481-9441
Mailing Address - Fax:520-296-8244
Practice Address - Street 1:6251 E 25TH ST
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711-6014
Practice Address - Country:US
Practice Address - Phone:520-481-9441
Practice Address - Fax:520-296-8244
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-17
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH4915385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZBH4915OtherAZ DHS LICENSE