Provider Demographics
NPI:1063501948
Name:SELECTIVE HEALTHCARE INC
Entity Type:Organization
Organization Name:SELECTIVE HEALTHCARE INC
Other - Org Name:NONE
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT , CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:MERI
Authorized Official - Middle Name:J
Authorized Official - Last Name:BACON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-533-8181
Mailing Address - Street 1:19841 N 68TH DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-5593
Mailing Address - Country:US
Mailing Address - Phone:623-533-8181
Mailing Address - Fax:623-362-2242
Practice Address - Street 1:19841 N 68TH DR
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-5593
Practice Address - Country:US
Practice Address - Phone:623-533-8181
Practice Address - Fax:623-362-2242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2011-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ584746Medicaid