=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063000255
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LORENA ACUNA CARE GIVER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/04/2021
-----------------------------------------------------
Last Update Date | 01/04/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1890 E WOODSMAN PL
-----------------------------------------------------
City | CHANDLER
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85286-1096
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-696-4158
-----------------------------------------------------
Fax | 480-625-3156
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1890 E WOODSMAN PL
-----------------------------------------------------
City | CHANDLER
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85286-1096
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-696-4158
-----------------------------------------------------
Fax | 480-625-3156
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 374U00000X
-----------------------------------------------------
Taxonomy Name | Home Health Aide
-----------------------------------------------------
License Number | AZ09205
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------