Healthcare Provider Details

I. General information

NPI: 1093855082
Provider Name (Legal Business Name): NOAHS ARK FAMILY CLINIC CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 12/10/2024
Certification Date: 12/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6707 N 19TH AVE STE 105
PHOENIX AZ
85015-1105
US

IV. Provider business mailing address

7800 N 55TH AVE STE 106&107
GLENDALE AZ
85301-1321
US

V. Phone/Fax

Practice location:
  • Phone: 480-247-7691
  • Fax: 480-919-7040
Mailing address:
  • Phone: 623-931-5001
  • Fax: 623-931-5120

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number
License Number StateNULL
# 7
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: DANNY NGUYEN
Title or Position: PRESIDENT/CEO
Credential: PRESIDENT/CEO
Phone: 480-332-8832