Provider Demographics
NPI:1134255136
Name:SAN CARLOS WELLNESS CENTER
Entity type:Organization
Organization Name:SAN CARLOS WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:AHMAD
Authorized Official - Middle Name:
Authorized Official - Last Name:DJANGI
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:928-475-4875
Mailing Address - Street 1:5 SAN CARLOS BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:SAN CARLOS
Mailing Address - State:AZ
Mailing Address - Zip Code:85550
Mailing Address - Country:US
Mailing Address - Phone:928-478-4875
Mailing Address - Fax:928-475-4880
Practice Address - Street 1:154 E. HWY 70
Practice Address - Street 2:
Practice Address - City:BYLAS
Practice Address - State:AZ
Practice Address - Zip Code:85530
Practice Address - Country:US
Practice Address - Phone:928-475-3450
Practice Address - Fax:928-475-3453
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10845101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty