Basic Information
| Provider Information | |||||||||
| NPI: | 1497021679 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TEQUA MED-PEDS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3269 MARICOPA AVE | ||||||||
| Address2: | SUITE 114-239 | ||||||||
| City: | LAKE HAVASU CITY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 864068593 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286695550 | ||||||||
| FaxNumber: | 9286690061 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 W RIVERSIDE DR | ||||||||
| Address2: | |||||||||
| City: | PARKER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853445119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286695550 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2012 | ||||||||
| LastUpdateDate: | 04/01/2012 | ||||||||
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| AuthorizedOfficialLastName: | SALEHI-RAD | ||||||||
| AuthorizedOfficialFirstName: | TEQUA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER/MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 9286695550 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 5436 | AZ | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | 5436 | AZ | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | L-1647527-7 | 01 | AZ | AZ-LLC REGISTRATION # | OTHER |