MEDICARE: GRAND CANYON HOME CARE INC.

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	3747A0650X	Attendant Care Provider

General Provider Information

NPI Number	:	1972805679
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRAND CANYON HOME CARE INC.

Provider Business Mailing Address
First Line	:	13201 N 35TH AVE STE 1B
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85029-1231
Country	:	US
Telephone Number	:	602-795-0222
Fax Number	:	602-795-0080

Provider Business Practice Location Address
First Line	:	13201 N 35TH AVE STE 1B
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85029-1231
Country	:	US
Telephone Number	:	602-795-0222
Fax Number	:	602-795-0080

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. YAKOV YUSHUVAYEV
Credential	:
Telephone Number	:	917-864-3328

Provider Enumeration Date	:	12/01/2010
Last Update Date	:	03/31/2023

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