Healthcare Provider Details

I. General information

NPI: 1164174272
Provider Name (Legal Business Name): ADULT GERIATRIC CARE GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/20/2022
Last Update Date: 05/30/2023
Certification Date: 05/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12451 W GENTLE RAIN RD
PEORIA AZ
85383-7198
US

IV. Provider business mailing address

20403 N LAKE PLEASANT RD STE 117-488
PEORIA AZ
85382-9702
US

V. Phone/Fax

Practice location:
  • Phone: 857-400-7436
  • Fax: 888-425-0427
Mailing address:
  • Phone: 857-400-7436
  • Fax: 888-425-0427

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. AMORY GODWIN CARINGAL GRIJALDO
Title or Position: NURSE PRACTITIONER/OWNER
Credential: AGACNP-BC
Phone: 602-687-3273