Provider Demographics
NPI:1205230489
Name:MAZIMO AZUCENA AFH
Entity Type:Organization
Organization Name:MAZIMO AZUCENA AFH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:MAXIMO
Authorized Official - Middle Name:DIMAUNAHAN
Authorized Official - Last Name:AZUCENA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-322-5328
Mailing Address - Street 1:10522 19TH PL W
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98204-3663
Mailing Address - Country:US
Mailing Address - Phone:425-322-5328
Mailing Address - Fax:425-322-5328
Practice Address - Street 1:10522 19TH PL W
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98204-3663
Practice Address - Country:US
Practice Address - Phone:425-322-5328
Practice Address - Fax:425-322-5328
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-16
Last Update Date:2014-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA751038302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1115019Medicaid