Basic Information
| Provider Information | |||||||||
| NPI: | 1023085115 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RED ROCK PEDIATRICS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 COVE PKWY | ||||||||
| Address2: | |||||||||
| City: | COTTONWOOD | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 863264644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286493003 | ||||||||
| FaxNumber: | 9286493030 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 COVE PKWY | ||||||||
| Address2: | |||||||||
| City: | COTTONWOOD | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 863264644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286493003 | ||||||||
| FaxNumber: | 9286493030 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2006 | ||||||||
| LastUpdateDate: | 06/24/2009 | ||||||||
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| AuthorizedOfficialLastName: | TUCCILLE | ||||||||
| AuthorizedOfficialFirstName: | WENDY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9286493003 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.