MEDICARE: HIS VILLAGE RESCUE MISSION

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
2	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1831667674
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HIS VILLAGE RESCUE MISSION

Provider Business Mailing Address
First Line	:	190 W CONTINENTAL RD STE 216-66
Second Line	:
City	:	GREEN VALLEY
State	:	AZ
Zip	:	85622-3500
Country	:	US
Telephone Number	:	704-765-2116
Fax Number	:

Provider Business Practice Location Address
First Line	:	5009 BEATTIES FORD RD # 107259
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28216-2859
Country	:	US
Telephone Number	:	704-765-2116
Fax Number	:

Authorized Official
Title or Position	:	MANAGING DIRECTOR
Name	:	LEAH GIBSON
Credential	:
Telephone Number	:	520-422-4016

Provider Enumeration Date	:	11/09/2018
Last Update Date	:	11/13/2024

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