MEDICARE: ITC PERSONAL IN-HOME CARE 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	385HR2060X	Child Intellectual and/or Developmental Disabilities Respite Care	479687	AZ

General Provider Information

NPI Number	:	1699023846
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ITC PERSONAL IN-HOME CARE LLC

Provider Business Mailing Address
First Line	:	1345 E MAIN ST STE 110
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85203-8950
Country	:	US
Telephone Number	:	480-969-5480
Fax Number	:	480-969-5512

Provider Business Practice Location Address
First Line	:	1345 E MAIN ST STE 110
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85203-8950
Country	:	US
Telephone Number	:	480-969-5480
Fax Number	:	480-969-5512

Authorized Official
Title or Position	:	OWNER
Name	:	MR. JOSH GONZALES
Credential	:
Telephone Number	:	480-969-5480

Provider Enumeration Date	:	08/20/2012
Last Update Date	:	08/20/2012

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