Provider Demographics
NPI:1235730508
Name:PATRUTESCU, GHEORGHE
Entity Type:Individual
Prefix:
First Name:GHEORGHE
Middle Name:
Last Name:PATRUTESCU
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 1:16134 N 72ND LN
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-4937
Mailing Address - Country:US
Mailing Address - Phone:602-370-6263
Mailing Address - Fax:623-776-7460
Practice Address - Street 1:16134 N 72ND LN
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-4937
Practice Address - Country:US
Practice Address - Phone:623-776-7460
Practice Address - Fax:623-776-7460
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL10530H310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ817449Medicaid