1821218801 NPI number — SAN CARLOS APACHE WELLNESS CENTER

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821218801 NPI number — SAN CARLOS APACHE WELLNESS CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAN CARLOS APACHE WELLNESS CENTER
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:
1821218801
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5 SAN CARLOS BOULEVARD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN CARLOS
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85550
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-475-4875
Provider Business Mailing Address Fax Number:
928-475-4880

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5 SAN CARLOS BOULEVARD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN CARLOS
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85550
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-475-4875
Provider Business Practice Location Address Fax Number:
928-475-4880
Provider Enumeration Date:
05/01/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DJANGI
Authorized Official First Name:
AHMAD
Authorized Official Middle Name:
REZA
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
928-475-4875

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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