Basic Information
| Provider Information | |||||||||
| NPI: | 1104143411 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARANA TEEN WELLNESS CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 188 | ||||||||
| Address2: | |||||||||
| City: | MARANA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856530188 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5206824560 | ||||||||
| FaxNumber: | 5206824570 | ||||||||
| Practice Location | |||||||||
| Address1: | 12000 W EMIGH RD | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857439696 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5206829128 | ||||||||
| FaxNumber: | 5206829136 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2010 | ||||||||
| LastUpdateDate: | 04/26/2010 | ||||||||
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| AuthorizedOfficialLastName: | SANDE | ||||||||
| AuthorizedOfficialFirstName: | DD | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 5206824560 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MARANA HEALTH CENTER | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | OTC0819 | AZ | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.