Healthcare Provider Details

I. General information

NPI: 1558085498
Provider Name (Legal Business Name): FOUNDATIONS PEDIATRIC CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2022
Last Update Date: 11/07/2023
Certification Date: 11/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5400 W NORTHERN AVE STE 101
GLENDALE AZ
85301-1590
US

IV. Provider business mailing address

1755 N PEBBLE CREEK PKWY PMB1058
GOODYEAR AZ
85395-2532
US

V. Phone/Fax

Practice location:
  • Phone: 480-847-0900
  • Fax: 480-508-7815
Mailing address:
  • Phone: 480-847-0900
  • Fax: 480-508-7815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. NAILAH COOPER
Title or Position: MEMBER MANAGER
Credential: MD
Phone: 480-847-0900