Provider Demographics
NPI:1013547686
Name:WESLEY COMMUNITY CENTER INC
Entity Type:Organization
Organization Name:WESLEY COMMUNITY CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BLAINE
Authorized Official - Middle Name:
Authorized Official - Last Name:BANDI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-368-9616
Mailing Address - Street 1:1300 S 10TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85034-4516
Mailing Address - Country:US
Mailing Address - Phone:602-368-9603
Mailing Address - Fax:
Practice Address - Street 1:1510 S 19TH DR STE 100
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85009-6540
Practice Address - Country:US
Practice Address - Phone:602-368-9896
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-22
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service