=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346988813
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PATRICIA ANN CRAIGMILES HOME LIFE CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2022
-----------------------------------------------------
Last Update Date | 05/24/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8414 W PAYSON RD
-----------------------------------------------------
City | TOLLESON
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85353-7620
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-216-9813
-----------------------------------------------------
Fax | 623-225-7188
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7709 S 69TH DR
-----------------------------------------------------
City | LAVEEN
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85339-3433
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. THADDEUS HIGHTOWER III
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 623-273-9040
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 177F00000X
-----------------------------------------------------
Taxonomy Name | Lodging Provider
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------