=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457892168
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KWD ENTERPRISE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2017
-----------------------------------------------------
Last Update Date | 03/14/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1325 W DUVAL MINE RD STE 119
-----------------------------------------------------
City | GREEN VALLEY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85614-5293
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-625-2050
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1325 W DUVAL MINE RD STE 119
-----------------------------------------------------
City | GREEN VALLEY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85614-5293
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-625-2050
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. KEITH W DAVIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 520-625-2050
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number | L-18-03755
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------