=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740271733
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFE CARE AT HOME OF ARIZONA, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/31/2005
-----------------------------------------------------
Last Update Date | 07/06/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1661 E CAMELBACK RD SUITE 255
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85016-3911
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-991-3303
-----------------------------------------------------
Fax | 480-922-4944
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3001 KEITH ST NW
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37312-3713
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-473-5256
-----------------------------------------------------
Fax | 423-339-8356
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP OF FINANCE
-----------------------------------------------------
Name | PAM RAU
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 423-473-5280
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | HHA 1446
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------