Provider Demographics
NPI:1669728713
Name:TRADITIONAL HOME CARE
Entity type:Organization
Organization Name:TRADITIONAL HOME CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:LULA
Authorized Official - Middle Name:M
Authorized Official - Last Name:NEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-871-5021
Mailing Address - Street 1:PO BOX 998
Mailing Address - Street 2:
Mailing Address - City:ST MICHAELS
Mailing Address - State:AZ
Mailing Address - Zip Code:86511-0998
Mailing Address - Country:US
Mailing Address - Phone:928-871-5021
Mailing Address - Fax:928-810-3998
Practice Address - Street 1:1/4 MILE N. TWO STORY RD.
Practice Address - Street 2:RA #31
Practice Address - City:ST. MICHAELS
Practice Address - State:AZ
Practice Address - Zip Code:86511
Practice Address - Country:US
Practice Address - Phone:928-871-5021
Practice Address - Fax:928-810-3998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-26
Last Update Date:2012-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ415780253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care