Provider Demographics
NPI:1558085498
Name:FOUNDATIONS PEDIATRIC CLINIC
Entity Type:Organization
Organization Name:FOUNDATIONS PEDIATRIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:NAILAH
Authorized Official - Middle Name:
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-847-0900
Mailing Address - Street 1:1755 N PEBBLE CREEK PKWY
Mailing Address - Street 2:PMB1058
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85395-2532
Mailing Address - Country:US
Mailing Address - Phone:480-847-0900
Mailing Address - Fax:480-508-7815
Practice Address - Street 1:5400 W NORTHERN AVE STE 101
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85301-1590
Practice Address - Country:US
Practice Address - Phone:480-847-0900
Practice Address - Fax:480-508-7815
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-03
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty