MEDICARE: 4TH GENERATION HOME CARE SERVICE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1578317467
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	4TH GENERATION HOME CARE SERVICE LLC

Provider Business Mailing Address
First Line	:	2 N CENTRAL AVE # 1810
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85004-2322
Country	:	US
Telephone Number	:	314-971-9784
Fax Number	:

Provider Business Practice Location Address
First Line	:	2 N CENTRAL AVE # 1810
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85004-2322
Country	:	US
Telephone Number	:	314-971-9784
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MS. NACOLE M TAYLOR
Credential	:
Telephone Number	:	314-971-9784

Provider Enumeration Date	:	04/16/2024
Last Update Date	:	04/16/2024

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