Healthcare Provider Details

I. General information

NPI: 1427065093
Provider Name (Legal Business Name): LITTLE RIVER RESPIRATORY CARE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5540 E BROADWAY RD SUITE 7
MESA AZ
85206-1440
US

IV. Provider business mailing address

5540 E BROADWAY RD SUITE 7
MESA AZ
85206-1440
US

V. Phone/Fax

Practice location:
  • Phone: 480-325-8011
  • Fax: 480-325-7796
Mailing address:
  • Phone: 480-325-8011
  • Fax: 480-325-7796

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number105930
License Number StateAZ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier551269
Identifier TypeMEDICAID
Identifier StateAZ
Identifier Issuer
# 2
Identifier00200886
Identifier TypeOTHER
Identifier StateAZ
Identifier IssuerSALES TAX LICENSE
# 3
Identifier07-30169-M
Identifier TypeOTHER
Identifier StateAZ
Identifier IssuerBUS RETAIL LICENSE
# 4
Identifier105930
Identifier TypeOTHER
Identifier StateAZ
Identifier IssuerBOARD OF PHARM O2 LICENSE

VIII. Authorized Official

Name: TERRY H FOX
Title or Position: PRESIDENT
Credential: RRT
Phone: 480-325-8011