Basic Information
| Provider Information | |||||||||
| NPI: | 1376986463 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HOSPICE AT HOME OF ARIZONA LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 FAULCONER DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTESVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229035089 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4349779711 | ||||||||
| FaxNumber: | 4349779715 | ||||||||
| Practice Location | |||||||||
| Address1: | 2500 S POWER RD STE 125A | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852096688 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4804780643 | ||||||||
| FaxNumber: | 4802846020 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2013 | ||||||||
| LastUpdateDate: | 02/17/2022 | ||||||||
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| AuthorizedOfficialLastName: | HUNTER | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | BRADLEY | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 4349779711 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | Y | Agencies | Hospice Care, Community Based |
ID Information
| ID | Type | State | Issuer | Description | 209433 | 05 | AZ | MEDICAID |