Provider Demographics
NPI:1609474030
Name:FISHER FAMILY HOME LLC
Entity Type:Organization
Organization Name:FISHER FAMILY HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:COLEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-282-3043
Mailing Address - Street 1:2927 W REDFIELD RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85053-7712
Mailing Address - Country:US
Mailing Address - Phone:602-548-1410
Mailing Address - Fax:602-942-6530
Practice Address - Street 1:2927 W REDFIELD RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85053-7712
Practice Address - Country:US
Practice Address - Phone:602-548-1410
Practice Address - Fax:602-942-6530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-16
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZA14420508Medicaid