Provider Demographics
NPI:1063068898
Name:AMBEST FAMILY HEALTH CLINICS, PLLC
Entity type:Organization
Organization Name:AMBEST FAMILY HEALTH CLINICS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / MEMBER MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:OKEY
Authorized Official - Middle Name:
Authorized Official - Last Name:ILOEGBUNAM
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:770-688-6691
Mailing Address - Street 1:4325 S OTIS RD
Mailing Address - Street 2:
Mailing Address - City:FORT MOHAVE
Mailing Address - State:AZ
Mailing Address - Zip Code:86426-6385
Mailing Address - Country:US
Mailing Address - Phone:770-688-6691
Mailing Address - Fax:
Practice Address - Street 1:4841 S MESA VILLAS DR APT 3
Practice Address - Street 2:
Practice Address - City:FORT MOHAVE
Practice Address - State:AZ
Practice Address - Zip Code:86426-6436
Practice Address - Country:US
Practice Address - Phone:928-577-7368
Practice Address - Fax:928-299-3373
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-16
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP22410618OtherCORPORATION ID
AZ576901Medicaid