Healthcare Provider Details

I. General information

NPI: 1841439932
Provider Name (Legal Business Name): DESERT VALLEY WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2009
Last Update Date: 02/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5310 W THUNDERBIRD RD SUITE 203
GLENDALE AZ
85306-4706
US

IV. Provider business mailing address

5310 W THUNDERBIRD RD SUITE 203
GLENDALE AZ
85306-4706
US

V. Phone/Fax

Practice location:
  • Phone: 602-548-6500
  • Fax: 602-993-0054
Mailing address:
  • Phone: 602-548-6500
  • Fax: 602-993-0054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number3259
License Number StateAZ

VIII. Authorized Official

Name: DEBI ROBERTSON
Title or Position: MEMBER
Credential:
Phone: 602-548-6500