MEDICARE: MRS. EVELYN IVY ECHOLS

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

General Provider Information

NPI Number	:	1104478825
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. EVELYN IVY ECHOLS

Provider Business Mailing Address
First Line	:	11821 N 28TH DR APT 293
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85029-3314
Country	:	US
Telephone Number	:	414-795-8198
Fax Number	:	602-354-5124

Provider Business Practice Location Address
First Line	:	11821 N 28TH DR APT 293
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85029-3314
Country	:	US
Telephone Number	:	414-795-8198
Fax Number	:	602-354-5124

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/12/2019
Last Update Date	:	07/12/2019

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