MEDICARE: ARIZONA HEALTHY CLINIC LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207QA0401X	Addiction Medicine (Family Medicine) Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1588299176
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ARIZONA HEALTHY CLINIC LLC

Provider Business Mailing Address
First Line	:	4344 W INDIAN SCHOOL RD STE 8
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85031-2939
Country	:	US
Telephone Number	:	623-594-2432
Fax Number	:	623-594-2438

Provider Business Practice Location Address
First Line	:	4344 W INDIAN SCHOOL RD STE 8
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85031-2939
Country	:	US
Telephone Number	:	623-594-2432
Fax Number	:	623-594-2438

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	DIANA SUAREZ
Credential	:	RMA
Telephone Number	:	623-594-2432

Provider Enumeration Date	:	03/04/2020
Last Update Date	:	03/04/2020

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