MEDICARE: EAST VALLEY WELLNESS CENTER, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician		AZ

General Provider Information

NPI Number	:	1023464542
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST VALLEY WELLNESS CENTER, LLC

Provider Business Mailing Address
First Line	:	PO BOX 52992
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85208-0150
Country	:	US
Telephone Number	:	480-373-2399
Fax Number	:	480-373-2396

Provider Business Practice Location Address
First Line	:	5656 S POWER RD
Second Line	:
City	:	GILBERT
State	:	AZ
Zip	:	85295-8480
Country	:	US
Telephone Number	:	480-373-2399
Fax Number	:	480-373-2396

Authorized Official
Title or Position	:	OWNER
Name	:	GARY A SMITH
Credential	:	M.D.
Telephone Number	:	480-373-2399

Provider Enumeration Date	:	05/13/2016
Last Update Date	:	03/26/2025

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