Provider Demographics
NPI:1922366947
Name:LIVING WATERS HOSPICE LLC
Entity Type:Organization
Organization Name:LIVING WATERS HOSPICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:DENHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:928-565-9000
Mailing Address - Street 1:4195 HIGHWAY 68,
Mailing Address - Street 2:C-902
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86413
Mailing Address - Country:US
Mailing Address - Phone:928-565-9000
Mailing Address - Fax:928-565-9001
Practice Address - Street 1:3711 US HIGHWAY 68
Practice Address - Street 2:
Practice Address - City:GOLDEN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86413-7522
Practice Address - Country:US
Practice Address - Phone:928-565-9000
Practice Address - Fax:928-565-9001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-27
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ031611Medicare Oscar/Certification