MEDICARE: AIMEE SUSANNE MIDKIFF CCG

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	AL12778H	AZ

General Provider Information

NPI Number	:	1932998143
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AIMEE SUSANNE MIDKIFF CCG

Provider Business Mailing Address
First Line	:	7859 E LAS FLORES AVE
Second Line	:
City	:	PRESCOTT VALLEY
State	:	AZ
Zip	:	86314-5540
Country	:	US
Telephone Number	:	929-277-0884
Fax Number	:	928-277-0946

Provider Business Practice Location Address
First Line	:	7859 E LAS FLORES AVE
Second Line	:
City	:	PRESCOTT VALLEY
State	:	AZ
Zip	:	86314-5540
Country	:	US
Telephone Number	:	929-277-0884
Fax Number	:	928-277-0946

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

Provider Enumeration Date	:	05/05/2025
Last Update Date	:	05/05/2025

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