=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780084301
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HYDE PARK HOME HEALTHCARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/02/2014
-----------------------------------------------------
Last Update Date | 09/02/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14850 N SCOTTSDALE RD #450-B
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85254-2798
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-250-0304
-----------------------------------------------------
Fax | 480-237-8770
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14850 N SCOTTSDALE RD #450-B
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85254-2798
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-250-0304
-----------------------------------------------------
Fax | 480-237-8770
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | JAN SHAFER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 623-330-2838
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | HHA5794
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------