Provider Demographics
NPI:1376835561
Name:WAITE, JOHN CHARLES
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:CHARLES
Last Name:WAITE
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 1:1161 N EL DORADO PL STE 103
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85715-4607
Mailing Address - Country:US
Mailing Address - Phone:520-748-7108
Mailing Address - Fax:
Practice Address - Street 1:8501 E SHILOH ST
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85710-2941
Practice Address - Country:US
Practice Address - Phone:520-490-5906
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-06
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
253J00000X
AZ2838615385HR2055X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency
No385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ613805Medicaid