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General NPI Number Information
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NPI Number | 1497246482
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Entity Type | Organization
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Legal Business Name | ARIZONA ESSENTIAL HOLISTIC CARE
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Dates
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Enumeration Date | 05/24/2018
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Last Update Date | 11/25/2019
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Provider Practice Location Address
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Address Line | 5700 W OLIVE AVE STE 102
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City | GLENDALE
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State | AZ
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Zip | 85302
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Country | US
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Telephone | 623-738-6062
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Fax | 602-354-9462
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Provider Business Mailing Address
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Address Line | 5700 W OLIVE AVE STE 102
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City | GLENDALE
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State | AZ
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Zip | 85302-3147
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Country | US
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Telephone | 602-738-6062
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Fax | 602-354-9462
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Authorized Official
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Title or Position | PROVIDER/OWNER
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Name | ALODIA BANUELOS DOMINGO
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Credential |
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Telephone | 623-738-6062
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | AP5625
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License Number State | AZ
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