Basic Information
| Provider Information | |||||||||
| NPI: | 1376835561 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAITE | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | CHARLES | ||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1161 N EL DORADO PL STE 103 | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857154607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5207487108 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8501 E SHILOH ST | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857102941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5204905906 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2011 | ||||||||
| LastUpdateDate: | 08/13/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 253J00000X | Y | Agencies | Foster Care Agency | 385HR2055X | 2838615 | AZ | N | Respite Care Facility | Respite Care | Respite Care, Mental Illness, Child |
ID Information
| ID | Type | State | Issuer | Description | 613805 | 05 | AZ | MEDICAID |