Provider Demographics
NPI:1245501188
Name:SAN PEDRO HEALTH PLLC
Entity type:Organization
Organization Name:SAN PEDRO HEALTH PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:PHILLIP
Authorized Official - Last Name:REED
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:520-515-9610
Mailing Address - Street 1:4151 LA LINDA WAY
Mailing Address - Street 2:SUITE # 102
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85635-4600
Mailing Address - Country:US
Mailing Address - Phone:520-515-9610
Mailing Address - Fax:520-515-0031
Practice Address - Street 1:4151 LA LINDA WAY
Practice Address - Street 2:SUITE # 102
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-4600
Practice Address - Country:US
Practice Address - Phone:520-515-9610
Practice Address - Fax:520-515-0031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-24
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2845261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ138176Medicare PIN