Provider Demographics
NPI:1912046566
Name:VASQUEZ, JUAN M (NONE)
Entity Type:Individual
Prefix:MR
First Name:JUAN
Middle Name:M
Last Name:VASQUEZ
Suffix:
Gender:M
Credentials:NONE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9264 S. WILT BANK RD.
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85735
Mailing Address - Country:US
Mailing Address - Phone:520-440-0630
Mailing Address - Fax:520-319-5491
Practice Address - Street 1:9264 S. WILT BANK ROAD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85735
Practice Address - Country:US
Practice Address - Phone:520-440-0630
Practice Address - Fax:520-319-5491
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2433320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ2433OtherBEHAVIORAL HEALTH NUMBER