Provider Demographics
NPI:1568559631
Name:LAS FUENTES HEALTH CLINIC
Entity Type:Organization
Organization Name:LAS FUENTES HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:WARD
Authorized Official - Last Name:MOLINA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-777-2263
Mailing Address - Street 1:8625 S AVENIDA DEL YAQUI
Mailing Address - Street 2:
Mailing Address - City:GUADALUPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85283-2504
Mailing Address - Country:US
Mailing Address - Phone:480-777-2263
Mailing Address - Fax:480-777-2264
Practice Address - Street 1:8625 S AVENIDA DEL YAQUI
Practice Address - Street 2:
Practice Address - City:GUADALUPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-2504
Practice Address - Country:US
Practice Address - Phone:480-777-2263
Practice Address - Fax:480-777-2264
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
28804Medicare ID - Type Unspecified