Provider Demographics
NPI:1073722765
Name:WICKENBURG HOME CARE
Entity Type:Organization
Organization Name:WICKENBURG HOME CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOOKKEEPER
Authorized Official - Prefix:MS
Authorized Official - First Name:LAFAYE
Authorized Official - Middle Name:J
Authorized Official - Last Name:HOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-684-3201
Mailing Address - Street 1:PO BOX 20237
Mailing Address - Street 2:
Mailing Address - City:WICKENBURG
Mailing Address - State:AZ
Mailing Address - Zip Code:85358-5237
Mailing Address - Country:US
Mailing Address - Phone:928-684-3201
Mailing Address - Fax:928-684-0684
Practice Address - Street 1:1020 W WICKENBURG WAY
Practice Address - Street 2:STE 4
Practice Address - City:WICKENBURG
Practice Address - State:AZ
Practice Address - Zip Code:85390-3290
Practice Address - Country:US
Practice Address - Phone:928-684-3201
Practice Address - Fax:928-684-0684
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZL13325529372500000X, 374U00000X, 376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered372500000XNursing Service Related ProvidersChore ProviderGroup - Multi-Specialty
Not Answered374U00000XNursing Service Related ProvidersHome Health AideGroup - Multi-Specialty
Not Answered376J00000XNursing Service Related ProvidersHomemakerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ198634Medicaid