Provider Demographics
NPI:1427604131
Name:VILLA, ROBERT ANTHONY (LAC, MACOM)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:ANTHONY
Last Name:VILLA
Suffix:
Gender:M
Credentials:LAC, MACOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2334 N CALLE RICARDO
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85716-2904
Mailing Address - Country:US
Mailing Address - Phone:804-683-2421
Mailing Address - Fax:
Practice Address - Street 1:9175 E TANQUE VERDE RD STE 101
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85749-8820
Practice Address - Country:US
Practice Address - Phone:520-398-4900
Practice Address - Fax:520-398-4995
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-18
Last Update Date:2019-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ010079171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist