Healthcare Provider Details

I. General information

NPI: 1649523556
Provider Name (Legal Business Name): PRINCE OF PEACE HOME HEALTHCARE LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2012
Last Update Date: 04/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10640 N 28TH DR STE A101
PHOENIX AZ
85029-2908
US

IV. Provider business mailing address

10640 N 28TH DR STE A101
PHOENIX AZ
85029-2908
US

V. Phone/Fax

Practice location:
  • Phone: 602-441-3501
  • Fax: 602-865-1970
Mailing address:
  • Phone: 602-441-3501
  • Fax: 602-865-1970

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number34308
License Number StateAZ

VIII. Authorized Official

Name: MRS. IMELDA G PRAKELT
Title or Position: PRESIDENT
Credential: LPN
Phone: 520-868-0250