MEDICARE: RESILIENCY PROVIDER SERVICES

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	385HR2060X	Child Intellectual and/or Developmental Disabilities Respite Care

General Provider Information

NPI Number	:	1568693950
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RESILIENCY PROVIDER SERVICES

Provider Business Mailing Address
First Line	:	12312 W DELWOOD DR
Second Line	:	PO BOX 3699
City	:	ARIZONA CITY
State	:	AZ
Zip	:	85223-5577
Country	:	US
Telephone Number	:	520-483-3439
Fax Number	:	520-437-0188

Provider Business Practice Location Address
First Line	:	12312 W DELWOOD DR
Second Line	:
City	:	ARIZONA CITY
State	:	AZ
Zip	:	85223-5577
Country	:	US
Telephone Number	:	520-483-3439
Fax Number	:	520-437-0188

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MS. RENEE EKANEM
Credential	:
Telephone Number	:	520-483-3439

Provider Enumeration Date	:	08/03/2009
Last Update Date	:	08/03/2009

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