MEDICARE: SPECTRUM HOME HEALTH CARE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251E00000X	Home Health Agency	HHA3953	AZ

General Provider Information

NPI Number	:	1053360644
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPECTRUM HOME HEALTH CARE, LLC

Provider Business Mailing Address
First Line	:	11512 E QUEENSBOROUGH AVE
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85212-4091
Country	:	US
Telephone Number	:	480-430-3052
Fax Number	:	480-452-1811

Provider Business Practice Location Address
First Line	:	840 W UNIVERSITY DR
Second Line	:	SUITE #3
City	:	MESA
State	:	AZ
Zip	:	85201-5529
Country	:	US
Telephone Number	:	480-430-3052
Fax Number	:	480-452-1811

Authorized Official
Title or Position	:	OWNER/ADMINISTRATOR
Name	:	DAREN TODD POVAR
Credential	:	PT
Telephone Number	:	480-430-3052

Provider Enumeration Date	:	05/09/2006
Last Update Date	:	03/12/2009

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