Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 111N00000X | Chiropractor | 5710 | AZ |
Y | 175F00000X | Naturopath | 09-1105 | AZ |
NPI | 1124026307 |
---|---|
Provider Name | Tracy B Peruch |
First Address | Glendale, AZ 85310-5956 |
Second Address | Glendale, AZ 85310-5956 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/07/2005 |
Last Update Date | 06/04/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1Z5304 | HEALTH NET (01) | AZ |
AZ0940160 | BLUE CROSS BLUE SHEILD (01) | AZ |
U65714 | (02) |