NPIMap

Organization Active NPI

Adelante Healthcare, Inc.

Doing business as Adelante Healthcare-Wickenburg

  • Federally Qualified Health Center (FQHC)
  • Wickenburg, AZ
National Provider Identifier
1083772545
Registry record updated Apr 28, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
ADELANTE HEALTHCARE, INC.
Doing business as
Adelante Healthcare-Wickenburg
Practice address
811 North Tegner
Suite 113
Wickenburg, AZ 85390-2226
Phone
(480) 964-2273
Fax
(623) 583-8330
NPI assigned
Dec 5, 2006
Last updated
Apr 28, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 28, 2023

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

Authorized official

Name
Krystal Powell
Title
Revenue Cycle Director
Phone
(623) 583-3001

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X NU Primary
Family Medicine Physician 207Q00000X AZ
Internal Medicine Physician 207R00000X AZ

Addresses

Primary practice location

811 North Tegner
Suite 113
Wickenburg, AZ 85390-2226

Mailing address

3033 N Central Ave Ste 145
Phoenix, AZ 85012-2808
Phone (623) 583-3001

Other names 1

  • Adelante Healthcare-Wickenburg Doing business as

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20031114000335 AZ Part B Supplier - Clinic/Group Practice 4688588643 Receives reassigned benefits from 250 practitioners
14 other NPIs on this enrollment
Practice locations: Gila Bend, AZ; Wickenburg, AZ; Surprise, AZ; Phoenix, AZ; Peoria, AZ; Mesa, AZ; Goodyear, AZ; Buckeye, AZ
O20080416000416 AZ Part A Provider - Federally Qualified Health Center (FQHC) 4688588643 Practice locations: Wickenburg, AZ

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1083772545. Details of each certification follow.

Federally qualified health center certification: CCN 031817

Legal name
ADELANTE HEALTHCARE, INC
Doing business as
ADELANTE HEALTHCARE-WICKENBURG
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Apr 5, 1994
Last certification
Apr 5, 1994
Ownership / control type
For profit – partnership
Organization structure
CorporationNon-profit
Incorporated
Jan 1, 1980 in AZ
Enrollment address
811 N Tegner St
Ste 113
Wickenburg, AZ 85390-5410
Related CCNs
031800

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 13

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

View all 13

Other NPIs on the same Medicare enrollment 13

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

View all 13

National Provider Directory

National Provider Directory

Locations

15351 W Bell Rd
Surprise, AZ 85374

Ownership & related parties

All disclosed owners & managing parties 22

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

NameRoleSinceShare
Angela J Robinson Individual Corporate OfficerChief Financial Officer May 10, 2021 10%
Jan Hertzfeld Individual Corporate DirectorBoard Member Jan 24, 2022
Robert D Babyar Individual Corporate OfficerChief Medical Officer Sep 6, 2016 10%
Lawrence Keith Sands Individual Corporate DirectorBoard Member May 23, 2013
Michael Ellenby Individual Corporate DirectorBoard Member Mar 22, 2018
Jason Reed Individual Corporate DirectorBoard Member Dec 21, 2017
Audrey Michelle Bohanan Individual Corporate OfficerCho Dec 11, 2011 10%
Guadalupe Campos Individual Corporate DirectorBoard Member Jan 10, 2022
Gordon L Grado Individual Corporate DirectorBoard Member Jul 23, 2015
Heather Boysel Individual Corporate DirectorBoard Member Jun 23, 2016
Sentari Mychale Minor Individual Corporate DirectorBoard Member Apr 3, 2015
Angie Mortemore Individual Corporate DirectorBoard Member Apr 3, 2015
Annette White Individual Corporate DirectorBoard Member Apr 25, 2019
Phillip Woy Taylor Individual Corporate DirectorBoard Member Jul 1, 2014
Gabriel Ramirez Individual Corporate DirectorBoard Member Sep 28, 2017
Nelida Acosta Individual Corporate DirectorBoard Member Feb 11, 2022
Jesse Garcia Individual Corporate OfficerChief Strategy Officer Jan 12, 2017 10%
Pedro Cons Individual Corporate OfficerChief Executive Officer Jul 6, 2020 15%
Darrell Wayne Leonard Individual Corporate DirectorBoard Member Mar 1, 2022
Krystal Powell Individual W-2 Managing EmployeeRevenue Cycle Director Apr 18, 2016
Jonae Harrison Individual Corporate OfficerChief Compliance Officer Mar 3, 2022 10%
Aelin Golsarry Individual Corporate OfficerChief Technology Officer Dec 14, 2021 10%

Owners & managing parties with NPI records 2

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

Practitioners & affiliated clinicians

Practitioners 262

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 262

NPI Registry JSON

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

{
    "created_epoch": "1165276800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1682640000000",
    "number": "1083772545",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3033 N CENTRAL AVE STE 145",
            "city": "PHOENIX",
            "state": "AZ",
            "postal_code": "850122808",
            "telephone_number": "623-583-3001",
            "fax_number": "623-876-9559"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "811 NORTH TEGNER",
            "address_2": "SUITE 113",
            "city": "WICKENBURG",
            "state": "AZ",
            "postal_code": "853902226",
            "telephone_number": "480-964-2273",
            "fax_number": "623-583-8330"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ADELANTE HEALTHCARE, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-12-05",
        "last_updated": "2023-04-28",
        "certification_date": "2023-04-28",
        "status": "A",
        "authorized_official_last_name": "POWELL",
        "authorized_official_first_name": "KRYSTAL",
        "authorized_official_title_or_position": "REVENUE CYCLE DIRECTOR",
        "authorized_official_telephone_number": "623-583-3001"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "AZ",
            "license": null,
            "primary": false
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "AZ",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Adelante Healthcare-Wickenburg",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Adelante Healthcare-Wickenburg",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Wickenburg, AZ

Sources for this page

Verify at the official NPI Registry.