Provider Demographics
NPI:1679789309
Name:ALFRED J. JUAN SR.
Entity type:Organization
Organization Name:ALFRED J. JUAN SR.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR A J MEDICAL TRANSPORT
Authorized Official - Prefix:MR
Authorized Official - First Name:ALFRED
Authorized Official - Middle Name:J
Authorized Official - Last Name:JUAN
Authorized Official - Suffix:SR
Authorized Official - Credentials:EMERGENCY MEDICAL TE
Authorized Official - Phone:520-383-1400
Mailing Address - Street 1:PO BOX 743
Mailing Address - Street 2:
Mailing Address - City:SELLS
Mailing Address - State:AZ
Mailing Address - Zip Code:85634-0743
Mailing Address - Country:US
Mailing Address - Phone:520-383-1400
Mailing Address - Fax:520-383-1400
Practice Address - Street 1:HOUSE AZ. 26-24-CH47
Practice Address - Street 2:A J MEDICAL TRANSPORT SAN ISIDRO COMM.
Practice Address - City:SELLS
Practice Address - State:AZ
Practice Address - Zip Code:85634
Practice Address - Country:US
Practice Address - Phone:520-383-1400
Practice Address - Fax:520-383-1400
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AJ MEDICAL TRANSPORT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-16
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZB40530146N00000X
AZAZ47621146N00000X
AZLP029559363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, BasicGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ487828OtherAVAILITY
AZ293808Medicaid