Provider Demographics
NPI:1164174272
Name:ADULT GERIATRIC CARE GROUP
Entity Type:Organization
Organization Name:ADULT GERIATRIC CARE GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:AMORY GODWIN
Authorized Official - Middle Name:CARINGAL
Authorized Official - Last Name:GRIJALDO
Authorized Official - Suffix:
Authorized Official - Credentials:AGACNP-BC
Authorized Official - Phone:602-687-3273
Mailing Address - Street 1:20403 N LAKE PLEASANT RD STE 117-488
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-9702
Mailing Address - Country:US
Mailing Address - Phone:857-400-7436
Mailing Address - Fax:888-425-0427
Practice Address - Street 1:12451 W GENTLE RAIN RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85383-7198
Practice Address - Country:US
Practice Address - Phone:857-400-7436
Practice Address - Fax:888-425-0427
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-20
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Single Specialty