Provider Demographics
NPI:1013088780
Name:SRC1 II LLC
Entity Type:Organization
Organization Name:SRC1 II LLC
Other - Org Name:SAFENET HOME HEALTH SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:KUZIA
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:480-946-4145
Mailing Address - Street 1:6240 E THOMAS RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85251-7017
Mailing Address - Country:US
Mailing Address - Phone:480-946-4145
Mailing Address - Fax:480-946-1280
Practice Address - Street 1:6240 E THOMAS RD
Practice Address - Street 2:SUITE 203
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85251-7017
Practice Address - Country:US
Practice Address - Phone:480-946-4145
Practice Address - Fax:480-946-1280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ037185251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ037185Medicare Oscar/Certification