Provider Demographics
NPI:1346548385
Name:KRESO, IBRAHIM
Entity Type:Individual
Prefix:
First Name:IBRAHIM
Middle Name:
Last Name:KRESO
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 1:121 E FOUR HORSES PL
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85704-7210
Mailing Address - Country:US
Mailing Address - Phone:520-742-5913
Mailing Address - Fax:520-742-5913
Practice Address - Street 1:121 E FOUR HORSES PL
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704-7210
Practice Address - Country:US
Practice Address - Phone:520-742-5913
Practice Address - Fax:520-742-5913
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-28
Last Update Date:2019-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH-3784320800000X
AZBH3784385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZBH3784OtherAZ DEPT OF HEALTH SERVICES