Healthcare Provider Details

I. General information

NPI: 1619436292
Provider Name (Legal Business Name): AZ WELLNESS CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2019
Last Update Date: 03/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6114 N 59TH AVE STE 4
GLENDALE AZ
85301-7769
US

IV. Provider business mailing address

6114 N 59TH AVE STE 4
GLENDALE AZ
85301-7769
US

V. Phone/Fax

Practice location:
  • Phone: 623-937-8643
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: LIBAN ALMAGUER
Title or Position: OWNER
Credential:
Phone: 623-937-8643