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General NPI Number Information
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NPI Number | 1619491495
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Entity Type | Organization
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Legal Business Name | I CARE GROUP HOME
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Dates
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Enumeration Date | 08/02/2017
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Last Update Date | 08/03/2017
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Provider Practice Location Address
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Address Line | 5529 E BLOOMFIELD RD
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City | SCOTTSDALE
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State | AZ
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Zip | 85254-4203
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Country | US
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Telephone | 480-302-1620
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Fax |
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Provider Business Mailing Address
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Address Line | 130 N 110TH DR
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City | AVONDALE
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State | AZ
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Zip | 85323-3323
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PROGRAM DIRECTOR
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Name | ELIJAH SISSE
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Credential |
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Telephone | 480-302-1620
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320800000X
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Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
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License Number | BH5232
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License Number State | AZ
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