Healthcare Provider Details

I. General information

NPI: 1427925122
Provider Name (Legal Business Name): PRESTIGE COMPANION CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2025
Last Update Date: 10/20/2025
Certification Date: 10/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

522 N CENTRAL AVE
PHOENIX AZ
85004-2185
US

IV. Provider business mailing address

522 N CENTRAL AVE
PHOENIX AZ
85004-2185
US

V. Phone/Fax

Practice location:
  • Phone: 480-331-3815
  • Fax:
Mailing address:
  • Phone: 480-331-3815
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332U00000X
TaxonomyHome Delivered Meals
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. GARY RANDALL MOORE
Title or Position: CEO
Credential:
Phone: 602-456-9358