Provider Demographics
NPI:1306141171
Name:BAILEY, CALVIN KEITH
Entity type:Individual
Prefix:
First Name:CALVIN
Middle Name:KEITH
Last Name:BAILEY
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 1:12168 W MIAMI ST
Mailing Address - Street 2:
Mailing Address - City:TOLLESON
Mailing Address - State:AZ
Mailing Address - Zip Code:85353-2741
Mailing Address - Country:US
Mailing Address - Phone:309-453-3130
Mailing Address - Fax:
Practice Address - Street 1:12168 W MIAMI ST
Practice Address - Street 2:
Practice Address - City:TOLLESON
Practice Address - State:AZ
Practice Address - Zip Code:85353-2741
Practice Address - Country:US
Practice Address - Phone:309-453-3130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-25
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8967733747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant