Healthcare Provider Details

I. General information

NPI: 1518038520
Provider Name (Legal Business Name): CACTUS WREN ASSISTED HOME CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6313 N 40TH DRIVE
PHOENIX AZ
85019-1427
US

IV. Provider business mailing address

6313 N 40TH DR
PHOENIX AZ
85019-1427
US

V. Phone/Fax

Practice location:
  • Phone: 602-741-5523
  • Fax:
Mailing address:
  • Phone: 602-741-5523
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberALH-5818
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberALH-5184
License Number StateAZ

VIII. Authorized Official

Name: MISS SHIRLETA CANOY SODEN
Title or Position: OWNER
Credential: R.N.
Phone: 602-741-5526