Provider Demographics
NPI:1497021679
Name:TEQUA MED-PEDS LLC
Entity Type:Organization
Organization Name:TEQUA MED-PEDS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:TEQUA
Authorized Official - Middle Name:
Authorized Official - Last Name:SALEHI-RAD
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:928-669-5550
Mailing Address - Street 1:3269 MARICOPA AVE
Mailing Address - Street 2:SUITE 114-239
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86406-8593
Mailing Address - Country:US
Mailing Address - Phone:928-669-5550
Mailing Address - Fax:928-669-0061
Practice Address - Street 1:601 W RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:PARKER
Practice Address - State:AZ
Practice Address - Zip Code:85344-5119
Practice Address - Country:US
Practice Address - Phone:928-669-5550
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-01
Last Update Date:2012-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5436207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZL-1647527-7OtherAZ-LLC REGISTRATION #