Healthcare Provider Details

I. General information

NPI: 1447733043
Provider Name (Legal Business Name): HIDDEN OASIS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2018
Last Update Date: 09/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6081 N DODGE DR
PRESCOTT VALLEY AZ
86314-1742
US

IV. Provider business mailing address

6081 N DODGE DR
PRESCOTT VALLEY AZ
86314-1742
US

V. Phone/Fax

Practice location:
  • Phone: 928-273-4442
  • Fax:
Mailing address:
  • Phone: 928-273-4442
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code315D00000X
TaxonomyInpatient Hospice
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code282E00000X
TaxonomyLong Term Care Hospital
License Number
License Number StateNULL

VIII. Authorized Official

Name: KARL HENDERSON
Title or Position: OWNER
Credential:
Phone: 928-273-4442