MEDICARE: CERTIFIED PA 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

General Provider Information

NPI Number	:	1497589626
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CERTIFIED PA LLC

Provider Business Mailing Address
First Line	:	3104 E CAMELBACK RD # 2306
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85016-4502
Country	:	US
Telephone Number	:	877-913-1733
Fax Number	:

Provider Business Practice Location Address
First Line	:	3104 E CAMELBACK RD # 2306
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85016-4502
Country	:	US
Telephone Number	:	877-913-1733
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	IMANI BOARD
Credential	:
Telephone Number	:	877-913-1733

Provider Enumeration Date	:	08/29/2024
Last Update Date	:	06/02/2026

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