Provider Demographics
NPI:1740494186
Name:TANQUE VERDE PEDIATRICS, P.C.
Entity type:Organization
Organization Name:TANQUE VERDE PEDIATRICS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICKEY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:520-722-2585
Mailing Address - Street 1:7265 E TANQUE VERDE RD
Mailing Address - Street 2:SUITE 121
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85715-3466
Mailing Address - Country:US
Mailing Address - Phone:520-722-2585
Mailing Address - Fax:520-722-1097
Practice Address - Street 1:7265 E TANQUE VERDE RD
Practice Address - Street 2:SUITE 121
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85715-3466
Practice Address - Country:US
Practice Address - Phone:520-722-2585
Practice Address - Fax:520-722-1097
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZ14264208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty