=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609632298
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CLINICA MEDICA FAMILIAR SAN GABRIEL, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/22/2024
-----------------------------------------------------
Last Update Date | 02/22/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4515 S MCCLINTOCK DR STE 115
-----------------------------------------------------
City | TEMPE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85282-7381
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-780-0690
-----------------------------------------------------
Fax | 480-831-0415
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4515 S MCCLINTOCK DR STE 115
-----------------------------------------------------
City | TEMPE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85282-7381
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-780-0690
-----------------------------------------------------
Fax | 480-831-0415
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MARIE E BENTZ
-----------------------------------------------------
Credential | DNP, FNP-C
-----------------------------------------------------
Telephone | 714-465-0875
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------