MEDICARE: CHAMBO WELLNESS CENTER, 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	207Q00000X	Family Medicine Physician	3615	AZ

General Provider Information

NPI Number	:	1699942268
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHAMBO WELLNESS CENTER, LLC

Provider Business Mailing Address
First Line	:	6740 W DEER VALLEY RD
Second Line	:	SUITE D107-255
City	:	GLENDALE
State	:	AZ
Zip	:	85310-5953
Country	:	US
Telephone Number	:	602-298-2653
Fax Number	:	602-298-2686

Provider Business Practice Location Address
First Line	:	4925 W BELL RD
Second Line	:	SUITE C7
City	:	GLENDALE
State	:	AZ
Zip	:	85308-3427
Country	:	US
Telephone Number	:	602-298-2653
Fax Number	:	602-298-2686

Authorized Official
Title or Position	:	MEDICAL DIRCECTOR
Name	:	GREGORY A BODE
Credential	:	DO
Telephone Number	:	602-298-2653

Provider Enumeration Date	:	05/13/2008
Last Update Date	:	05/13/2008

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