Provider Demographics
NPI:1518038520
Name:CACTUS WREN ASSISTED HOME CARE LLC
Entity type:Organization
Organization Name:CACTUS WREN ASSISTED HOME CARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:SHIRLETA
Authorized Official - Middle Name:CANOY
Authorized Official - Last Name:SODEN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:602-741-5526
Mailing Address - Street 1:6313 N 40TH DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85019-1427
Mailing Address - Country:US
Mailing Address - Phone:602-741-5523
Mailing Address - Fax:
Practice Address - Street 1:6313 N 40TH DRIVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85019-1427
Practice Address - Country:US
Practice Address - Phone:602-741-5523
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZALH-5818311ZA0620X
AZALH-5184311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ113906Medicaid
AZ943771Medicaid