Provider Demographics
NPI:1902179302
Name:AEGIS HOMECARE, INC
Entity Type:Organization
Organization Name:AEGIS HOMECARE, INC
Other - Org Name:AEGIS HOMECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:LARSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-754-4962
Mailing Address - Street 1:7227 E BASELINE RD STE 127
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85209-5006
Mailing Address - Country:US
Mailing Address - Phone:480-219-4790
Mailing Address - Fax:480-584-5871
Practice Address - Street 1:7227 E BASELINE RD STE 127
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85209-5006
Practice Address - Country:US
Practice Address - Phone:480-219-4790
Practice Address - Fax:480-584-5871
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-15
Last Update Date:2019-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ03D2038146OtherCLIA WAIVER
AZ746297Medicaid
AZHHA5406OtherARIZONA STATE LICENSE
AZ03D2038146OtherCLIA WAIVER