Healthcare Provider Details

I. General information

NPI: 1497587554
Provider Name (Legal Business Name): KOCCH HAVEN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2024
Last Update Date: 08/16/2024
Certification Date: 08/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6428 S 23RD AVE
PHOENIX AZ
85041-5357
US

IV. Provider business mailing address

21289 S 187TH WAY
QUEEN CREEK AZ
85142-3668
US

V. Phone/Fax

Practice location:
  • Phone: 832-513-5993
  • Fax:
Mailing address:
  • Phone: 832-513-5993
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: CHIKODILI C UBA
Title or Position: MEMBER MANAGER
Credential: RN
Phone: 832-513-5993