MEDICARE: PRESTIGE PERSONAL 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	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1881257848
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRESTIGE PERSONAL CARE LLC

Provider Business Mailing Address
First Line	:	3000 E MAIN ST STE B
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43209-3717
Country	:	US
Telephone Number	:	602-677-7193
Fax Number	:

Provider Business Practice Location Address
First Line	:	2415 E CAMELBACK RD STE 774
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85016-4288
Country	:	US
Telephone Number	:	602-677-7193
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	HAREGEWYIN HABTE
Credential	:
Telephone Number	:	602-677-7193

Provider Enumeration Date	:	04/16/2019
Last Update Date	:	04/16/2019

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