Provider Demographics
NPI:1407472467
Name:HEALTHY YOU
Entity Type:Organization
Organization Name:HEALTHY YOU
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:OMAR
Authorized Official - Middle Name:L
Authorized Official - Last Name:DOMINIQUE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:872-212-7966
Mailing Address - Street 1:1441 E GERMANN RD APT 3091
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85286-1825
Mailing Address - Country:US
Mailing Address - Phone:872-212-7966
Mailing Address - Fax:602-888-8540
Practice Address - Street 1:9700 N 91ST ST STE A115
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258-5036
Practice Address - Country:US
Practice Address - Phone:480-770-3967
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-24
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02887009Medicaid
MS1770996050OtherNPI