MEDICARE: ARIZONA CHRISTIAN CARE, 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	311ZA0620X	Adult Care Home Facility	AL8928H	AZ

General Provider Information

NPI Number	:	1790114759
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ARIZONA CHRISTIAN CARE, LLC

Provider Business Mailing Address
First Line	:	1002 W PONTIAC DR
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85027-5713
Country	:	US
Telephone Number	:	602-715-2716
Fax Number	:	602-715-2795

Provider Business Practice Location Address
First Line	:	1002 W PONTIAC DR
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85027-5713
Country	:	US
Telephone Number	:	602-715-2716
Fax Number	:	602-715-2795

Authorized Official
Title or Position	:	OWNER
Name	:	TIMOTHY JORDAN DAVIS
Credential	:
Telephone Number	:	602-451-5263

Provider Enumeration Date	:	11/10/2013
Last Update Date	:	11/10/2013

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