MEDICARE: DOS ABUELOS ARIZONA 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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1609301795
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DOS ABUELOS ARIZONA LLC

Provider Business Mailing Address
First Line	:	3118 W THOMAS RD STE 712
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85017-5308
Country	:	US
Telephone Number	:	602-388-4017
Fax Number	:

Provider Business Practice Location Address
First Line	:	820 W DANFORTH RD # 105
Second Line	:
City	:	EDMOND
State	:	OK
Zip	:	73003-5006
Country	:	US
Telephone Number	:	405-697-7062
Fax Number	:

Authorized Official
Title or Position	:	CORPORATE ADMINISTRATOR
Name	:	TYRAE J WORD
Credential	:
Telephone Number	:	602-388-4017

Provider Enumeration Date	:	04/26/2017
Last Update Date	:	02/19/2026

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