Provider Demographics
NPI:1700029022
Name:SACRED MOUNTAIN HOME CARE
Entity Type:Organization
Organization Name:SACRED MOUNTAIN HOME CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:TONY
Authorized Official - Middle Name:DERALD
Authorized Official - Last Name:LILLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-612-9119
Mailing Address - Street 1:PO BOX 315
Mailing Address - Street 2:
Mailing Address - City:ST MICHAELS
Mailing Address - State:AZ
Mailing Address - Zip Code:86511-0315
Mailing Address - Country:US
Mailing Address - Phone:505-612-9119
Mailing Address - Fax:
Practice Address - Street 1:2 MILES WEST OF DAYS INN ON HWY 264
Practice Address - Street 2:
Practice Address - City:ST. MICHAELS
Practice Address - State:AZ
Practice Address - Zip Code:86511-0315
Practice Address - Country:US
Practice Address - Phone:505-612-9119
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-16
Last Update Date:2009-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health