Provider Demographics
NPI:1245011006
Name:MADE WHOLE MEDICAL CENTER LLC
Entity type:Organization
Organization Name:MADE WHOLE MEDICAL CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CAREMLA
Authorized Official - Middle Name:J
Authorized Official - Last Name:BANKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-300-6457
Mailing Address - Street 1:13048 W RANCHO SANTA FE BLVD
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85392-1705
Mailing Address - Country:US
Mailing Address - Phone:623-300-6457
Mailing Address - Fax:855-300-5330
Practice Address - Street 1:13048 W RANCHO SANTA FE BLVD
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85392-1705
Practice Address - Country:US
Practice Address - Phone:623-300-6457
Practice Address - Fax:855-300-5330
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CLINICAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-10-09
Last Update Date:2023-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No251B00000XAgenciesCase ManagementGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QF0050XAmbulatory Health Care FacilitiesClinic/CenterFamily Planning, Non-Surgical
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QV0200XAmbulatory Health Care FacilitiesClinic/CenterVA
No261QP2400XAmbulatory Health Care FacilitiesClinic/CenterPrison Health
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Multi-Specialty