Healthcare Provider Details

I. General information

NPI: 1013547686
Provider Name (Legal Business Name): WESLEY COMMUNITY CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2020
Last Update Date: 04/09/2021
Certification Date: 04/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 S 19TH DR STE 100
PHOENIX AZ
85009-6540
US

IV. Provider business mailing address

1300 S 10TH ST
PHOENIX AZ
85034-4516
US

V. Phone/Fax

Practice location:
  • Phone: 602-368-9896
  • Fax:
Mailing address:
  • Phone: 602-368-9603
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BLAINE BANDI
Title or Position: CEO
Credential:
Phone: 602-368-9616