NPIMap

Organization Active NPI

Wesley Community Center Inc

  • Federally Qualified Health Center (FQHC)
  • Phoenix, AZ
National Provider Identifier
1013547686
Registry record updated Apr 9, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
WESLEY COMMUNITY CENTER INC
Practice address
1510 S 19TH Dr Ste 100
Phoenix, AZ 85009-6540
Phone
(602) 368-9896
NPI assigned
Jan 22, 2020
Last updated
Apr 9, 2021By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 9, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Blaine Bandi
Title
Ceo
Phone
(602) 368-9616

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X Primary
Health Service Clinic/Center 261QH0100X

Addresses

Primary practice location

1510 S 19TH Dr Ste 100
Phoenix, AZ 85009-6540

Mailing address

1300 S 10TH St
Phoenix, AZ 85034-4516
Phone (602) 368-9603

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AZ2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20100407000432 AZ Part B Supplier - Clinic/Group Practice 9032264239 Receives reassigned benefits from 33 practitioners
3 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Mesa, AZ; Phoenix, AZ
O20220118002308 AZ Part A Provider - Federally Qualified Health Center (FQHC) 9032264239 Practice locations: Phoenix, AZ

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1013547686. Details of each certification follow.

Federally qualified health center certification: CCN 031008

Legal name
WESLEY COMMUNITY CENTER INC
Doing business as
COFFELT HEALTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jan 18, 2022
Last certification
Jan 18, 2022
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Jun 3, 1968 in AZ
Enrollment address
1510 S 19TH Dr
Ste 100
Phoenix, AZ 85009-6540

Other NPIs with the same Medicare PAC ID 3

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 3

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
03D2203577Wesley Health Center at Coffelt1510 S 19TH Dr Ste 100, Phoenix, AZ 85009Certificate of waiverDec 3, 2026

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 14

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Virginia a Cons Individual Corporate Director Jan 29, 2014
Jeff a Sandquist Individual Corporate Director Dec 19, 2019
Leila Semino Barraza Individual Corporate DirectorBoard Vice-President Jan 22, 2019
Marcus Childs Individual Corporate DirectorBoard Member May 25, 2021
Harry Garewal Individual Corporate DirectorBoard Member Dec 19, 2019
Megan Vaughan Individual Corporate DirectorBoard Member May 25, 2021
Nenette Parra Individual Corporate DirectorBoard Member Jun 23, 2021
Sonya Wilkins Individual Corporate OfficerChief Financial Officer Jul 6, 2015
W-2 Managing EmployeeChief Financial Officer Jul 6, 2015
Gary Lee Cloud Individual Corporate DirectorBoard President Aug 22, 2017
Alberta Farnsworth Individual Corporate DirectorBoard Member Aug 25, 2020
Blaine G Bandi Individual Corporate OfficerChief Executive Officer Aug 29, 2016 100%
W-2 Managing EmployeeChief Executive Officer Aug 29, 2016
Wendy a Redford Individual W-2 Managing EmployeeMedical Director Mar 12, 2021
Nancy Hook Individual Corporate DirectorBoard Member Jun 22, 2021
Jason Forrest Rentscheler Individual Corporate OfficerChief Operating Officer Dec 16, 2019
W-2 Managing EmployeeChief Operating Officer Dec 16, 2019

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Practitioners & affiliated clinicians

Practitioners 18

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 18

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1579651200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1617926400000",
    "number": "1013547686",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1300 S 10TH ST",
            "city": "PHOENIX",
            "state": "AZ",
            "postal_code": "850344516",
            "telephone_number": "602-368-9603"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1510 S 19TH DR STE 100",
            "city": "PHOENIX",
            "state": "AZ",
            "postal_code": "850096540",
            "telephone_number": "602-368-9896"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WESLEY COMMUNITY CENTER INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-01-22",
        "last_updated": "2021-04-09",
        "certification_date": "2021-04-09",
        "status": "A",
        "authorized_official_last_name": "BANDI",
        "authorized_official_first_name": "BLAINE",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "602-368-9616"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "261QH0100X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Health Service",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Phoenix, AZ

Sources for this page

Verify at the official NPI Registry.