MEDICARE: CASA DE ESPERANZA, INC.

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	251S00000X	Community/Behavioral Health Agency
2	251V00000X	Voluntary or Charitable Agency	AL0553D	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1124195284
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CASA DE ESPERANZA, INC.

Provider Business Mailing Address
First Line	:	780 S PARK CENTRE AVE
Second Line	:
City	:	GREEN VALLEY
State	:	AZ
Zip	:	85614-5127
Country	:	US
Telephone Number	:	520-625-2273
Fax Number	:

Provider Business Practice Location Address
First Line	:	780 S PARK CENTRE AVE
Second Line	:
City	:	GREEN VALLEY
State	:	AZ
Zip	:	85614-5127
Country	:	US
Telephone Number	:	520-625-2273
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. WILLIAM T MCCREERY
Credential	:	LPC
Telephone Number	:	520-625-2273

Provider Enumeration Date	:	11/30/2006
Last Update Date	:	08/02/2011

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