Healthcare Provider Details

I. General information

NPI: 1033819362
Provider Name (Legal Business Name): SMALL VICTORIES WELLNESS CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2023
Last Update Date: 03/06/2023
Certification Date: 03/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15640 N 7TH ST BLDG B
PHOENIX AZ
85022-3512
US

IV. Provider business mailing address

15640 N 7TH ST BLDG B
PHOENIX AZ
85022-3512
US

V. Phone/Fax

Practice location:
  • Phone: 469-774-9195
  • Fax:
Mailing address:
  • Phone: 469-774-9195
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name: ASHEL CHINGAYA
Title or Position: CEO
Credential:
Phone: 469-774-9159