Healthcare Provider Details

I. General information

NPI: 1447645833
Provider Name (Legal Business Name): AZ ADVANCED CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2015
Last Update Date: 04/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3137 W LANE AVE
PHOENIX AZ
85051-6522
US

IV. Provider business mailing address

3137 W LANE AVE
PHOENIX AZ
85051-6522
US

V. Phone/Fax

Practice location:
  • Phone: 602-332-0780
  • Fax: 877-517-2224
Mailing address:
  • Phone: 602-332-0780
  • Fax: 877-517-2224

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberAL9510H
License Number StateAZ

VIII. Authorized Official

Name: REBECCA T. SIDDIQUI
Title or Position: ADMINISTRATOR
Credential:
Phone: 602-332-0780