Provider Demographics
NPI:1649457193
Name:TINY TOTS PEDIATRICS LLC
Entity type:Organization
Organization Name:TINY TOTS PEDIATRICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARYLOU
Authorized Official - Middle Name:
Authorized Official - Last Name:REYES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-763-7020
Mailing Address - Street 1:PO BOX 23245
Mailing Address - Street 2:
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86439-3245
Mailing Address - Country:US
Mailing Address - Phone:928-763-7020
Mailing Address - Fax:
Practice Address - Street 1:2020 SILVERCREEK ROAD
Practice Address - Street 2:SUITE 114 BULIDING A
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442
Practice Address - Country:US
Practice Address - Phone:928-763-7020
Practice Address - Fax:928-763-7050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-28
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ28997208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty