=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235489147
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HOSPICE OF THE SOUTHWEST - WEST VALLEY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/18/2012
-----------------------------------------------------
Last Update Date | 09/18/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5055 E BROADWAY BLVD STE D-205
-----------------------------------------------------
City | TUCSON
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85711-3625
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-230-4450
-----------------------------------------------------
Fax | 520-230-4451
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5055 E BROADWAY BLVD STE D-205
-----------------------------------------------------
City | TUCSON
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85711-3625
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-230-4450
-----------------------------------------------------
Fax | 520-230-4451
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING PARTNER
-----------------------------------------------------
Name | RICHARD E BASS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 602-717-4751
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208VP0000X
-----------------------------------------------------
Taxonomy Name | Pain Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------