MEDICARE: AGAPECARE 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	324500000X	Substance Abuse Rehabilitation Facility

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	BH7961	OTHER	AZ	ARIZONA DEPARTMENT OF HEALTH SERVICES

General Provider Information

NPI Number	:	1992426308
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AGAPECARE LLC

Provider Business Mailing Address
First Line	:	6724 S 4TH ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85042-7685
Country	:	US
Telephone Number	:	937-430-1469
Fax Number	:

Provider Business Practice Location Address
First Line	:	1656 W PIEDMONT RD
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85041-3757
Country	:	US
Telephone Number	:	937-430-1469
Fax Number	:

Authorized Official
Title or Position	:	CEO/ADMINISTRATOR
Name	:	MRS. EMERYNE GAHIMBARE
Credential	:
Telephone Number	:	937-430-1469

Provider Enumeration Date	:	09/06/2022
Last Update Date	:	09/06/2022

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Directions to “AGAPECARE LLC ” Practice Location

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