MEDICARE: CHILD ENRICHMENT CENTER 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	385HR2060X	Child Intellectual and/or Developmental Disabilities Respite Care	263162747	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	26-3162747	OTHER	CA	TAX ID

General Provider Information

NPI Number	:	1104119411
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHILD ENRICHMENT CENTER LLC

Provider Business Mailing Address
First Line	:	2942 N 24TH ST STE 114642
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85016-7844
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2942 N 24TH ST STE 114642
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85016-7844
Country	:	US
Telephone Number	:	858-524-6399
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MS. SARAH HAWS
Credential	:	MSCP, BCBA
Telephone Number	:	808-284-7225

Provider Enumeration Date	:	05/18/2011
Last Update Date	:	05/18/2011

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