Healthcare Provider Details

I. General information

NPI: 1104946771
Provider Name (Legal Business Name): BELLAIR MEDICAL CLINIC, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17250 N 43RD AVE SUITE 4
GLENDALE AZ
85308-4035
US

IV. Provider business mailing address

17250 N 43RD AVE SUITE 4
GLENDALE AZ
85308-4035
US

V. Phone/Fax

Practice location:
  • Phone: 602-978-4157
  • Fax: 602-938-8064
Mailing address:
  • Phone: 602-978-4157
  • Fax: 602-938-8064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number6919
License Number StateAZ

VIII. Authorized Official

Name: DR. AMOR C. VILLAREAL
Title or Position: TRUSTEE
Credential: M.D.
Phone: 602-978-4157