| Organization Name: | MARANA TEEN WELLNESS CENTER |
| NPI Number: | 1003133067 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | DD SANDE (CREDENTIALING SPECIALIST) |
| Mailing Address: | 13644 N Sandario Rd Marana |
| State: | AZ US |
| Postal Code: | 856538579 |
| Phone Number: | 5206824730 |
| Fax Number: | 5206824790 |
| NPI Enumeration Date: | 04/29/2010 |
| NPI Last Update Date: | 04/29/2010 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QF0400X |
| License Number: | OTC 0820 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | AZ |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Federally Qualified Health Center (FQHC) |
| Taxonomy Definition: | |