=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104483460
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TROY BERKLEY HOME HEALTH AID
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2019
-----------------------------------------------------
Last Update Date | 06/11/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18210 N 29TH ST
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85032-1103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-302-1101
-----------------------------------------------------
Fax | 480-546-3131
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18210 N 29TH ST
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85032-1103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-302-1101
-----------------------------------------------------
Fax | 480-546-3131
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number | AL10509H
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------