MEDICARE: BLACK MOUNTAIN BLESSING 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	253Z00000X	In Home Supportive Care Agency	288318	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

General Provider Information

NPI Number	:	1144715087
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLACK MOUNTAIN BLESSING LLC

Provider Business Mailing Address
First Line	:	706 E BELL RD STE 120
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85022-6655
Country	:	US
Telephone Number	:	602-362-3317
Fax Number	:	602-344-9043

Provider Business Practice Location Address
First Line	:	706 E BELL RD STE 120
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85022-6655
Country	:	US
Telephone Number	:	602-362-3317
Fax Number	:	602-344-9043

Authorized Official
Title or Position	:	OWNER/MEMBER
Name	:	AARON ROBERT STOUGH
Credential	:
Telephone Number	:	602-362-3317

Provider Enumeration Date	:	06/23/2018
Last Update Date	:	06/23/2018

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