Healthcare Provider Details

I. General information

NPI: 1245011006
Provider Name (Legal Business Name): MADE WHOLE MEDICAL CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2023
Last Update Date: 10/21/2023
Certification Date: 10/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13048 W RANCHO SANTA FE BLVD
AVONDALE AZ
85392-1705
US

IV. Provider business mailing address

13048 W RANCHO SANTA FE BLVD
AVONDALE AZ
85392-1705
US

V. Phone/Fax

Practice location:
  • Phone: 623-300-6457
  • Fax: 855-300-5330
Mailing address:
  • Phone: 623-300-6457
  • Fax: 855-300-5330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QF0050X
TaxonomyNon-Surgical Family Planning Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code261QP2400X
TaxonomyPrison Health Clinic/Center
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code261QV0200X
TaxonomyVA Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CAREMLA J BANKS
Title or Position: OWNER
Credential:
Phone: 623-300-6457