Healthcare Provider Details

I. General information

NPI: 1477801173
Provider Name (Legal Business Name): CJK HEALTH CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2012
Last Update Date: 09/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12409 W INDIAN SCHOOL RD STE B210
AVONDALE AZ
85392-9505
US

IV. Provider business mailing address

PO BOX 64642
PHOENIX AZ
85082-4642
US

V. Phone/Fax

Practice location:
  • Phone: 623-935-9920
  • Fax: 602-889-5834
Mailing address:
  • Phone: 602-889-5833
  • Fax: 602-889-5834

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: CHRISTOPHER JOHN KELSCH
Title or Position: OWNER
Credential: DC
Phone: 623-935-9920