Provider Demographics
NPI:1699942268
Name:CHAMBO WELLNESS CENTER, LLC
Entity type:Organization
Organization Name:CHAMBO WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRCECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:A
Authorized Official - Last Name:BODE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:602-298-2653
Mailing Address - Street 1:6740 W DEER VALLEY RD
Mailing Address - Street 2:SUITE D107-255
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85310-5953
Mailing Address - Country:US
Mailing Address - Phone:602-298-2653
Mailing Address - Fax:602-298-2686
Practice Address - Street 1:4925 W BELL RD
Practice Address - Street 2:SUITE C7
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-3427
Practice Address - Country:US
Practice Address - Phone:602-298-2653
Practice Address - Fax:602-298-2686
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-13
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3615207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty