Provider Demographics
NPI:1033819362
Name:SMALL VICTORIES WELLNESS CLINIC LLC
Entity Type:Organization
Organization Name:SMALL VICTORIES WELLNESS CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ASHEL
Authorized Official - Middle Name:
Authorized Official - Last Name:CHINGAYA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-774-9159
Mailing Address - Street 1:15640 N 7TH ST BLDG B
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85022-3512
Mailing Address - Country:US
Mailing Address - Phone:469-774-9195
Mailing Address - Fax:
Practice Address - Street 1:15640 N 7TH ST BLDG B
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85022-3512
Practice Address - Country:US
Practice Address - Phone:469-774-9195
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-06
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health