=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972141422
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AV CARE AGENCY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/16/2019
-----------------------------------------------------
Last Update Date | 12/16/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2267 S 173RD DR
-----------------------------------------------------
City | GOODYEAR
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85338-1961
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-248-4342
-----------------------------------------------------
Fax | 623-248-6096
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2267 S 173RD DR
-----------------------------------------------------
City | GOODYEAR
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85338-1961
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-248-4342
-----------------------------------------------------
Fax | 623-248-6096
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ADMIN
-----------------------------------------------------
Name | ANGELA MUHAMMAD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 803-600-6939
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320900000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------