Provider Demographics
NPI:1083199806
Name:GRAND DESERT HOME HEALTH, LLC
Entity Type:Organization
Organization Name:GRAND DESERT HOME HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ELMIRA
Authorized Official - Middle Name:
Authorized Official - Last Name:KOHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-274-8800
Mailing Address - Street 1:29 W THOMAS RD STE 204
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-4412
Mailing Address - Country:US
Mailing Address - Phone:602-274-8800
Mailing Address - Fax:
Practice Address - Street 1:29 W THOMAS RD STE 204
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-4412
Practice Address - Country:US
Practice Address - Phone:602-274-8800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-27
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ555574Medicaid