Healthcare Provider Details

I. General information

NPI: 1245778323
Provider Name (Legal Business Name): COPPER BASIN HEALTHCARE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2017
Last Update Date: 01/16/2025
Certification Date: 01/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6719 E 2ND ST STE A
PRESCOTT VALLEY AZ
86314-2661
US

IV. Provider business mailing address

6719 E 2ND ST STE A
PRESCOTT VALLEY AZ
86314-2661
US

V. Phone/Fax

Practice location:
  • Phone: 928-632-0111
  • Fax: 928-632-0333
Mailing address:
  • Phone: 928-632-0111
  • Fax: 928-632-0333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number
License Number State

VIII. Authorized Official

Name: AMBER L TUELLER
Title or Position: SECRETARY
Credential:
Phone: 208-207-2726