Provider Demographics
NPI:1992466510
Name:PIMACARE AT HOME
Entity type:Organization
Organization Name:PIMACARE AT HOME
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:WENDELL
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:520-258-5068
Mailing Address - Street 1:8467 E BROADWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85710-4009
Mailing Address - Country:US
Mailing Address - Phone:520-305-3445
Mailing Address - Fax:
Practice Address - Street 1:600 S COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85716-5807
Practice Address - Country:US
Practice Address - Phone:520-305-3445
Practice Address - Fax:520-289-8920
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PIMA COUNCIL ON AGING, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-01-05
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ578717Medicaid