Provider Demographics
NPI:1710262639
Name:DANIELS, ARDELL CLAY
Entity Type:Individual
Prefix:
First Name:ARDELL
Middle Name:CLAY
Last Name:DANIELS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18115 W CARDINAL DR
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-5112
Mailing Address - Country:US
Mailing Address - Phone:602-931-3683
Mailing Address - Fax:623-873-6127
Practice Address - Street 1:18115 W CARDINAL DR
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-5112
Practice Address - Country:US
Practice Address - Phone:602-931-3683
Practice Address - Fax:623-873-6127
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-12
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ234348171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ234348OtherCHRISTAIN FAMILY CARE