Healthcare Provider Details

I. General information

NPI: 1124482864
Provider Name (Legal Business Name): THE LITTLE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2016
Last Update Date: 10/22/2025
Certification Date: 10/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4204 W CACTUS RD
PHOENIX AZ
85029
US

IV. Provider business mailing address

4204 W CACTUS RD
PHOENIX AZ
85029-2924
US

V. Phone/Fax

Practice location:
  • Phone: 602-547-5919
  • Fax: 602-547-7023
Mailing address:
  • Phone: 602-547-5919
  • Fax: 602-547-7023

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberAP8609
License Number StateAZ

VIII. Authorized Official

Name: MR. THOMAS SHELLY
Title or Position: VP & GENERAL MANAGER
Credential:
Phone: 615-425-4287