Provider Demographics
NPI:1083917199
Name:WATERMARK HOME CARE OF SOUTHERN ARIZONA, LLC
Entity Type:Organization
Organization Name:WATERMARK HOME CARE OF SOUTHERN ARIZONA, LLC
Other - Org Name:WATERMARK AT HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:BARNES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-797-4000
Mailing Address - Street 1:2020 W RUDASILL RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85704-7800
Mailing Address - Country:US
Mailing Address - Phone:520-797-4000
Mailing Address - Fax:520-797-7757
Practice Address - Street 1:5830 N FOUNTAINS AVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704-2869
Practice Address - Country:US
Practice Address - Phone:520-886-4400
Practice Address - Fax:520-290-1900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-10
Last Update Date:2011-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZHHA4958251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ194925Medicaid
AZ194925Medicaid