Provider Demographics
NPI:1699431726
Name:WESLEY COMMUNITY CENTER, INC
Entity type:Organization
Organization Name:WESLEY COMMUNITY CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:BLAINE
Authorized Official - Middle Name:
Authorized Official - Last Name:BANDI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-368-9616
Mailing Address - Street 1:1300 S 10TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85034-4516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5845 E STILL CIR STE 104
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-3635
Practice Address - Country:US
Practice Address - Phone:602-257-4323
Practice Address - Fax:602-252-5768
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WESLEY COMMUNITY CENTER, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-11-12
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)