MEDICARE: MY DOC AT HOME, 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	163W00000X	Registered Nurse	RN161499	AZ

General Provider Information

NPI Number	:	1659816247
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MY DOC AT HOME, LLC

Provider Business Mailing Address
First Line	:	8633 W SHAW BUTTE DR
Second Line	:
City	:	PEORIA
State	:	AZ
Zip	:	85345-8186
Country	:	US
Telephone Number	:	623-980-6670
Fax Number	:

Provider Business Practice Location Address
First Line	:	8633 W SHAW BUTTE DR
Second Line	:
City	:	PEORIA
State	:	AZ
Zip	:	85345-8186
Country	:	US
Telephone Number	:	623-980-6670
Fax Number	:

Authorized Official
Title or Position	:	OWNER/OPERATOR
Name	:	CHRISTINE ALANE CHAMPINE
Credential	:	RN
Telephone Number	:	623-980-6670

Provider Enumeration Date	:	01/05/2017
Last Update Date	:	01/05/2017

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