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General NPI Number Information
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NPI Number | 1487037198
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Entity Type | Organization
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Legal Business Name | MADERA WELLNESS CENTER, LLC
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Dates
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Enumeration Date | 06/30/2015
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Last Update Date | 06/30/2015
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Provider Practice Location Address
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Address Line | 7107 E THOMAS RD
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City | SCOTTSDALE
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State | AZ
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Zip | 85251-6559
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Country | US
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Telephone | 480-463-4793
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Fax |
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Provider Business Mailing Address
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Address Line | 1628 W GLENROSA AVE
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City | PHOENIX
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State | AZ
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Zip | 85015-4734
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Country | US
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Telephone | 480-463-4793
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Fax |
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Authorized Official
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Title or Position | CEO/OWNER
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Name | JOSE LUIS MADERA JR.
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Credential | MSC,LPC
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Telephone | 480-463-4793
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State |
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