=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053303008
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEALTH EXCHANGE OF ARIZONA, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/16/2005
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1130 E MISSOURI AVE SUITE 404
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85014-2718
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-265-9606
-----------------------------------------------------
Fax | 602-265-9605
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1130 E MISSOURI AVE SUITE 404
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85014-2718
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-265-9606
-----------------------------------------------------
Fax | 602-265-9605
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/C.E.O.
-----------------------------------------------------
Name | MR. RICHARD I. BLOOM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 602-265-9606
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251J00000X
-----------------------------------------------------
Taxonomy Name | Nursing Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------