MEDICARE: FOUNDATION HOME HEALTH 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		AZ

General Provider Information

NPI Number	:	1811402332
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FOUNDATION HOME HEALTH LLC

Provider Business Mailing Address
First Line	:	1695 MESQUITE AVE STE 206
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-5688
Country	:	US
Telephone Number	:	928-493-4410
Fax Number	:	928-302-1907

Provider Business Practice Location Address
First Line	:	1695 MESQUITE AVE STE 206
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-5688
Country	:	US
Telephone Number	:	928-493-4410
Fax Number	:	928-302-1907

Authorized Official
Title or Position	:	COO
Name	:	MR. JERRY SHACKELFORD JR.
Credential	:	BSN
Telephone Number	:	928-493-4410

Provider Enumeration Date	:	12/06/2017
Last Update Date	:	06/06/2022

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Directions to “FOUNDATION HOME HEALTH LLC ” Practice Location

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