Healthcare Provider Details

I. General information

NPI: 1568559631
Provider Name (Legal Business Name): LAS FUENTES HEALTH CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8625 S AVENIDA DEL YAQUI
GUADALUPE AZ
85283-2504
US

IV. Provider business mailing address

8625 S AVENIDA DEL YAQUI
GUADALUPE AZ
85283-2504
US

V. Phone/Fax

Practice location:
  • Phone: 480-777-2263
  • Fax: 480-777-2264
Mailing address:
  • Phone: 480-777-2263
  • Fax: 480-777-2264

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN WARD MOLINA
Title or Position: CEO
Credential: M.D.
Phone: 480-777-2263