=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316240955
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FIRST CHOICE IN HOME CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/20/2010
-----------------------------------------------------
Last Update Date | 12/20/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3321 SOUTH MOORE CIRCLE
-----------------------------------------------------
City | FLAGSTAFF
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-607-8834
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3321 S MOORE CIR
-----------------------------------------------------
City | FLAGSTAFF
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86001-8501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-607-8834
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE MEMBER/ MANAGER
-----------------------------------------------------
Name | MR. DWIGHT C BOYD II
-----------------------------------------------------
Credential | N/A
-----------------------------------------------------
Telephone | 928-607-8834
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 302F00000X
-----------------------------------------------------
Taxonomy Name | Exclusive Provider Organization
-----------------------------------------------------
License Number | 302F00000X
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------