Healthcare Provider Details

I. General information

NPI: 1518246305
Provider Name (Legal Business Name): INK HEALTHCARE GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2011
Last Update Date: 02/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8020 N 12TH ST
PHOENIX AZ
85020-3802
US

IV. Provider business mailing address

PO BOX 26362
PHOENIX AZ
85068-6362
US

V. Phone/Fax

Practice location:
  • Phone: 602-218-5391
  • Fax:
Mailing address:
  • Phone: 602-218-5391
  • Fax: 602-427-0088

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License NumberL16865045
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License NumberL16865045
License Number StateAZ

VIII. Authorized Official

Name: JOHN VAUGHN
Title or Position: OWNER
Credential:
Phone: 602-218-5391