Provider Demographics
NPI:1104309152
Name:SIFUENTES, CARLOS
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:
Last Name:SIFUENTES
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 1:10750 W MCDOWELL RD.
Mailing Address - Street 2:STE. B-210
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85323
Mailing Address - Country:US
Mailing Address - Phone:623-907-0746
Mailing Address - Fax:
Practice Address - Street 1:10750 W MCDOWELL RD.
Practice Address - Street 2:STE. B-210
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85323
Practice Address - Country:US
Practice Address - Phone:623-907-0746
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-14
Last Update Date:2018-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPT-30258225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist