MEDICARE: KOCCH HAVEN LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	251E00000X	Home Health Agency
2	385H00000X	Respite Care
3	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1497587554
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KOCCH HAVEN LLC

Provider Business Mailing Address
First Line	:	21289 S 187TH WAY
Second Line	:
City	:	QUEEN CREEK
State	:	AZ
Zip	:	85142-3668
Country	:	US
Telephone Number	:	832-513-5993
Fax Number	:

Provider Business Practice Location Address
First Line	:	6428 S 23RD AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85041-5357
Country	:	US
Telephone Number	:	832-513-5993
Fax Number	:

Authorized Official
Title or Position	:	MEMBER MANAGER
Name	:	CHIKODILI C UBA
Credential	:	RN
Telephone Number	:	832-513-5993

Provider Enumeration Date	:	08/16/2024
Last Update Date	:	08/16/2024

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