Basic Information
| Provider Information | |||||||||
| NPI: | 1992714778 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HOSPICE OF ARIZONA, LC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 50 N LAURA ST | ||||||||
| Address2: | SUITE 1800 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322023664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9044936745 | ||||||||
| FaxNumber: | 9042624804 | ||||||||
| Practice Location | |||||||||
| Address1: | 19820 N 7TH AVE | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850274736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6026781313 | ||||||||
| FaxNumber: | 6022422178 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2006 | ||||||||
| LastUpdateDate: | 09/13/2012 | ||||||||
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| AuthorizedOfficialLastName: | FOGLE | ||||||||
| AuthorizedOfficialFirstName: | RICH | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9044936745 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | HSPC0050 | AZ | Y | Agencies | Hospice Care, Community Based |
ID Information
| ID | Type | State | Issuer | Description | 193475 | 05 | AZ | MEDICAID |