MEDICARE: MRS. COCA AIDA HADJIPENTCHEV

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	310400000X	Assisted Living Facility	ALH-5691	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	082984	OTHER	AZ	AHCCCS PROVIDER ID

General Provider Information

NPI Number	:	1922271485
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. COCA AIDA HADJIPENTCHEV

Provider Business Mailing Address
First Line	:	1020 W PONTIAC DR
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85027-5713
Country	:	US
Telephone Number	:	623-748-8108
Fax Number	:	623-466-7753

Provider Business Practice Location Address
First Line	:	1020 W PONTIAC DR
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85027-5713
Country	:	US
Telephone Number	:	623-748-8108
Fax Number	:	623-466-7753

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/04/2008
Last Update Date	:	04/04/2008

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