MEDICARE: NORTHEAST PHOENIX AZ CAREGIVING 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	:	1740959386
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHEAST PHOENIX AZ CAREGIVING LLC

Provider Business Mailing Address
First Line	:	209 S 28TH ST
Second Line	:
City	:	WACO
State	:	TX
Zip	:	76710-7415
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2224 W NORTHERN AVE # D208
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85021-4928
Country	:	US
Telephone Number	:	440-578-7799
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MICHAEL HILLMAN
Credential	:
Telephone Number	:	254-400-2625

Provider Enumeration Date	:	09/08/2021
Last Update Date	:	09/08/2021

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