Healthcare Provider Details

I. General information

NPI: 1396475844
Provider Name (Legal Business Name): POTTERVILLE CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2022
Last Update Date: 06/15/2022
Certification Date: 06/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3107 E FRANKLIN AVE
GILBERT AZ
85295-9093
US

IV. Provider business mailing address

3107 E FRANKLIN AVE
GILBERT AZ
85295-9093
US

V. Phone/Fax

Practice location:
  • Phone: 623-312-8093
  • Fax:
Mailing address:
  • Phone: 623-312-8093
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code385HR2065X
TaxonomyChild Physical Disabilities Respite Care
License Number
License Number State

VIII. Authorized Official

Name: DR. TAIWO AJAYI
Title or Position: MANAGING MEMBER
Credential: PHD
Phone: 623-312-8093