Provider Demographics
NPI:1659708287
Name:ENCISO, VICENTE O III
Entity Type:Individual
Prefix:MR
First Name:VICENTE
Middle Name:O
Last Name:ENCISO
Suffix:III
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 1:11721 W JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85323-1195
Mailing Address - Country:US
Mailing Address - Phone:623-313-4655
Mailing Address - Fax:
Practice Address - Street 1:8611 N 67TH AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85302-4351
Practice Address - Country:US
Practice Address - Phone:623-939-9475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-27
Last Update Date:2013-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5589A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant