MEDICARE: PRIVUS HEALTHCARE, 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	251B00000X	Case Management Agency

General Provider Information

NPI Number	:	1922417567
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRIVUS HEALTHCARE, LLC

Provider Business Mailing Address
First Line	:	22601 N 19TH AVE STE 114
Second Line	:	SUITE 114
City	:	PHOENIX
State	:	AZ
Zip	:	85027-1324
Country	:	US
Telephone Number	:	602-595-5197
Fax Number	:	602-595-6041

Provider Business Practice Location Address
First Line	:	22601 N 19TH AVE STE 114
Second Line	:	SUITE 114
City	:	PHOENIX
State	:	AZ
Zip	:	85027-1324
Country	:	US
Telephone Number	:	602-595-5197
Fax Number	:	602-595-6041

Authorized Official
Title or Position	:	MANAGER
Name	:	MATTHEW PEREZ
Credential	:
Telephone Number	:	602-595-5197

Provider Enumeration Date	:	08/07/2014
Last Update Date	:	08/07/2014

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