MEDICARE: EMPOWERMENT 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	261QR0401X	Comprehensive Outpatient Rehabilitation Facility (CORF)
2	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1780405043
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EMPOWERMENT ARIZONA LLC

Provider Business Mailing Address
First Line	:	5501 N 19TH AVE STE 430
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85015-2481
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5501 N 19TH AVE STE 430
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85015-2481
Country	:	US
Telephone Number	:	602-524-5521
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	JIMMY EVANS
Credential	:
Telephone Number	:	602-524-5521

Provider Enumeration Date	:	10/21/2024
Last Update Date	:	10/21/2024

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