Healthcare Provider Details

I. General information

NPI: 1275284234
Provider Name (Legal Business Name): AMANDA'S CARE HOME II LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2022
Last Update Date: 01/13/2022
Certification Date: 01/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8647 E PAMPA AVE
MESA AZ
85212-1787
US

IV. Provider business mailing address

3459 E VAUGHN AVE
GILBERT AZ
85234-4247
US

V. Phone/Fax

Practice location:
  • Phone: 480-373-8437
  • Fax:
Mailing address:
  • Phone: 909-434-6940
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code311Z00000X
TaxonomyCustodial Care Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. DAVID WANJE
Title or Position: OWNER
Credential:
Phone: 909-434-6940