Provider Demographics
NPI:1053035881
Name:AVISTA HOSPICE ARIZONA, LLC
Entity type:Organization
Organization Name:AVISTA HOSPICE ARIZONA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED AGENT
Authorized Official - Prefix:
Authorized Official - First Name:CANDICE
Authorized Official - Middle Name:
Authorized Official - Last Name:FINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-244-9173
Mailing Address - Street 1:1930 N ARBOLEDA STE 215
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85213-3217
Mailing Address - Country:US
Mailing Address - Phone:480-244-9173
Mailing Address - Fax:
Practice Address - Street 1:2415 S SIGNAL BUTTE RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85209-2107
Practice Address - Country:US
Practice Address - Phone:480-907-5588
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-26
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based