=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154856474
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMMUNITY CARE PARTNERS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2017
-----------------------------------------------------
Last Update Date | 06/05/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12035 N SAGUARO BLVD STE 203
-----------------------------------------------------
City | FOUNTAIN HILLS
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85268
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-256-3986
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12035 N SAGUARO BLVD STE 203
-----------------------------------------------------
City | FOUNTAIN HILLS
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85268-4647
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-462-2950
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | KELLI L CASADY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 480-462-2950
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207QA0505X
-----------------------------------------------------
Taxonomy Name | Adult Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------