Healthcare Provider Details

I. General information

NPI: 1821464082
Provider Name (Legal Business Name): FAMILY MEDICAL AND WELLNESS CARE, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2015
Last Update Date: 08/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 W BERYL AVE
PHOENIX AZ
85021-1606
US

IV. Provider business mailing address

4530 E RAY RD STE 130
PHOENIX AZ
85044-6094
US

V. Phone/Fax

Practice location:
  • Phone: 602-424-7967
  • Fax:
Mailing address:
  • Phone: 480-494-2100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number26147
License Number StateAZ

VIII. Authorized Official

Name: REBECCA GOLDMAN
Title or Position: OWNER/MD
Credential: MD
Phone: 480-861-8229