MEDICARE: HIDDEN OASIS, 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	282E00000X	Long Term Care Hospital
2	315D00000X	Inpatient Hospice

General Provider Information

NPI Number	:	1447733043
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HIDDEN OASIS, LLC

Provider Business Mailing Address
First Line	:	6081 N DODGE DR
Second Line	:
City	:	PRESCOTT VALLEY
State	:	AZ
Zip	:	86314-1742
Country	:	US
Telephone Number	:	928-273-4442
Fax Number	:

Provider Business Practice Location Address
First Line	:	6081 N DODGE DR
Second Line	:
City	:	PRESCOTT VALLEY
State	:	AZ
Zip	:	86314-1742
Country	:	US
Telephone Number	:	928-273-4442
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KARL HENDERSON
Credential	:
Telephone Number	:	928-273-4442

Provider Enumeration Date	:	09/10/2018
Last Update Date	:	09/10/2018

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