Healthcare Provider Details

I. General information

NPI: 1831373091
Provider Name (Legal Business Name): MARYVALE FAMILY PRACTICE GROUP INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/24/2007
Last Update Date: 04/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 N 51ST AVE SUITE 6
PHOENIX AZ
85031-1237
US

IV. Provider business mailing address

4700 N 51ST AVE SUITE 6
PHOENIX AZ
85031-1237
US

V. Phone/Fax

Practice location:
  • Phone: 623-209-5555
  • Fax: 623-247-1905
Mailing address:
  • Phone: 623-209-5555
  • Fax: 623-247-1905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: AVETIS ORDAKIAN
Title or Position: PRESIDENT
Credential:
Phone: 623-209-5555