Provider Demographics
NPI:1912469453
Name:BEDOYA, LOUIS
Entity Type:Individual
Prefix:
First Name:LOUIS
Middle Name:
Last Name:BEDOYA
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 1:33727 S COLONY DR
Mailing Address - Street 2:
Mailing Address - City:RED ROCK
Mailing Address - State:AZ
Mailing Address - Zip Code:85145-5044
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:33727 S COLONY DR
Practice Address - Street 2:
Practice Address - City:RED ROCK
Practice Address - State:AZ
Practice Address - Zip Code:85145-5044
Practice Address - Country:US
Practice Address - Phone:520-404-2232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-03
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7173970385HR2055X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ7173970OtherAZ DEPT OF HEALTH SERVICES