1497246482 NPI number — ARIZONA ESSENTIAL HOLISTIC CARE

Table of content: (NPI 1497246482)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497246482 NPI number — ARIZONA ESSENTIAL HOLISTIC CARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ARIZONA ESSENTIAL HOLISTIC CARE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1497246482
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/25/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5700 W OLIVE AVE STE 102
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GLENDALE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85302-3147
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-738-6062
Provider Business Mailing Address Fax Number:
602-354-9462

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5700 W OLIVE AVE STE 102
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GLENDALE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85302
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-738-6062
Provider Business Practice Location Address Fax Number:
602-354-9462
Provider Enumeration Date:
05/24/2018

Additional Information

Authorized Official

Authorized Official Last Name:
DOMINGO
Authorized Official First Name:
ALODIA
Authorized Official Middle Name:
BANUELOS
Authorized Official Title or Position:
PROVIDER/OWNER
Authorized Official Telephone Number:
623-738-6062

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  AP5625 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 811065660 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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