Provider Demographics
NPI:1376276360
Name:ULTIMATE PHYSICAL AND MENTAL HEALTH CLINIC LLC
Entity type:Organization
Organization Name:ULTIMATE PHYSICAL AND MENTAL HEALTH CLINIC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PATIENCE
Authorized Official - Middle Name:RONKE
Authorized Official - Last Name:AKHIMIEN
Authorized Official - Suffix:
Authorized Official - Credentials:DNP
Authorized Official - Phone:310-956-0556
Mailing Address - Street 1:16336 W MORELAND ST
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-6291
Mailing Address - Country:US
Mailing Address - Phone:623-213-7135
Mailing Address - Fax:623-213-8162
Practice Address - Street 1:13350 N 94TH DR STE B102
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-4826
Practice Address - Country:US
Practice Address - Phone:310-956-0556
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-06
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE1243713OtherDMV