Provider Demographics
NPI:1811402332
Name:FOUNDATION HOME HEALTH LLC
Entity Type:Organization
Organization Name:FOUNDATION HOME HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:SHACKELFORD
Authorized Official - Suffix:JR
Authorized Official - Credentials:BSN
Authorized Official - Phone:928-493-4410
Mailing Address - Street 1:1695 MESQUITE AVE STE 206
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-5688
Mailing Address - Country:US
Mailing Address - Phone:928-493-4410
Mailing Address - Fax:928-302-1907
Practice Address - Street 1:1695 MESQUITE AVE STE 206
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5688
Practice Address - Country:US
Practice Address - Phone:928-493-4410
Practice Address - Fax:928-302-1907
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-06
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health