Healthcare Provider Details

I. General information

NPI: 1316320997
Provider Name (Legal Business Name): FOUR SEASONS HOME HEALTH CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2015
Last Update Date: 07/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

64 W DINE HOUSING ST LOT 12
SHIPROCK NM
87420
US

IV. Provider business mailing address

PO BOX 53
SHIPROCK NM
87420-0053
US

V. Phone/Fax

Practice location:
  • Phone: 505-635-3071
  • Fax:
Mailing address:
  • Phone: 505-635-3071
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number101883
License Number StateNM

VIII. Authorized Official

Name: MRS. VIVIAN BENALLY
Title or Position: CEO/ OWNER
Credential:
Phone: 505-635-3071