Healthcare Provider Details

I. General information

NPI: 1356919583
Provider Name (Legal Business Name): GRAND CANYON WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2021
Last Update Date: 06/14/2021
Certification Date: 06/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2423 W DUNLAP AVE STE 110
PHOENIX AZ
85021-2830
US

IV. Provider business mailing address

2423 W DUNLAP AVE STE 110
PHOENIX AZ
85021-2830
US

V. Phone/Fax

Practice location:
  • Phone: 702-677-7410
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: NIECEY BOLDEN
Title or Position: OWNER
Credential:
Phone: 702-677-7410