Provider Demographics
NPI:1336586031
Name:PADILLA, JEROME
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:
Last Name:PADILLA
Suffix:
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:PO BOX 454
Mailing Address - Street 2:
Mailing Address - City:RED VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86544-0454
Mailing Address - Country:US
Mailing Address - Phone:505-635-4456
Mailing Address - Fax:505-564-2550
Practice Address - Street 1:7 1/2 MILES WEST OF RED ROCK TRADING
Practice Address - Street 2:
Practice Address - City:RED VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86544-4540
Practice Address - Country:US
Practice Address - Phone:505-635-4456
Practice Address - Fax:505-564-2550
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-04
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ808774343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)