Healthcare Provider Details

I. General information

NPI: 1649722000
Provider Name (Legal Business Name): GOLDEN HEART CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2016
Last Update Date: 04/23/2026
Certification Date: 04/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21620 N 19TH AVE STE A6
PHOENIX AZ
85027-2716
US

IV. Provider business mailing address

21620 N 19TH AVE STE A6
PHOENIX AZ
85027-2716
US

V. Phone/Fax

Practice location:
  • Phone: 623-248-1162
  • Fax: 623-248-4570
Mailing address:
  • Phone: 623-606-1907
  • Fax: 623-248-4570

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CARLOS VILLICANA
Title or Position: PRESIDENT
Credential:
Phone: 623-248-1162