Provider Demographics
NPI:1497246482
Name:ARIZONA ESSENTIAL HOLISTIC CARE
Entity Type:Organization
Organization Name:ARIZONA ESSENTIAL HOLISTIC CARE
Other - Org Name:ARIZONA ESSENTIAL HOLISTIC CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROVIDER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALODIA
Authorized Official - Middle Name:BANUELOS
Authorized Official - Last Name:DOMINGO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-738-6062
Mailing Address - Street 1:5700 W OLIVE AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85302-3147
Mailing Address - Country:US
Mailing Address - Phone:602-738-6062
Mailing Address - Fax:602-354-9462
Practice Address - Street 1:5700 W OLIVE AVE STE 102
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85302
Practice Address - Country:US
Practice Address - Phone:623-738-6062
Practice Address - Fax:602-354-9462
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-24
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP5625207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ811065660OtherUNITED HEALTH CARE