Healthcare Provider Details

I. General information

NPI: 1275783003
Provider Name (Legal Business Name): PRESTIGE HOME HEALTH CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2008
Last Update Date: 06/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3120 N 19TH AVE SUITE 170
PHOENIX AZ
85015-6052
US

IV. Provider business mailing address

PO BOX 18951
PHOENIX AZ
85005-8951
US

V. Phone/Fax

Practice location:
  • Phone: 602-279-8471
  • Fax: 602-279-0296
Mailing address:
  • Phone: 602-279-8471
  • Fax: 602-279-0296

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. BOLAN B OGUNDE
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 602-739-7170