Provider Demographics
NPI:1790936136
Name:APODACA, EDWARD RAY SR
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:RAY
Last Name:APODACA
Suffix:SR
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:HC 3 BOX 956
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85739-8632
Mailing Address - Country:US
Mailing Address - Phone:520-825-2403
Mailing Address - Fax:
Practice Address - Street 1:HC 3 BOX 956
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85739-8632
Practice Address - Country:US
Practice Address - Phone:520-825-2403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-03
Last Update Date:2008-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1101504385HR2055X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child