Provider Demographics
NPI:1508838517
Name:CATHOLIC COMMUNITY SERVICES IN SOUTHERN ARIZONA
Entity Type:Organization
Organization Name:CATHOLIC COMMUNITY SERVICES IN SOUTHERN ARIZONA
Other - Org Name:CATHOLIC COMMUNITY SERVICES IN SOUTHEASTERN ARIZONA HOME HEALTH PROGRA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR HOME HEALTH PROGRAM
Authorized Official - Prefix:MS
Authorized Official - First Name:RADI ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:PORTER
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:520-432-2285
Mailing Address - Street 1:PO BOX 1777
Mailing Address - Street 2:
Mailing Address - City:BISBEE
Mailing Address - State:AZ
Mailing Address - Zip Code:85603-2777
Mailing Address - Country:US
Mailing Address - Phone:520-432-2285
Mailing Address - Fax:520-432-2009
Practice Address - Street 1:#19 HOWELL AVENUE
Practice Address - Street 2:
Practice Address - City:BISBEE
Practice Address - State:AZ
Practice Address - Zip Code:85603
Practice Address - Country:US
Practice Address - Phone:520-432-2285
Practice Address - Fax:520-432-2009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HHA0112163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WH0200XNursing Service ProvidersRegistered NurseHome HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ652190Medicaid
037099Medicare ID - Type Unspecified