Provider Demographics
NPI:1295213544
Name:GRAND CANYON HOME CARE INC.
Entity type:Organization
Organization Name:GRAND CANYON HOME CARE INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:YAKOV
Authorized Official - Middle Name:
Authorized Official - Last Name:YUSHUVAYEV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-222-7666
Mailing Address - Street 1:13201 N 35TH AVE STE 4B
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85029-1231
Mailing Address - Country:US
Mailing Address - Phone:602-795-0222
Mailing Address - Fax:
Practice Address - Street 1:420 E SOUTHERN AVE STE 110A
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-4945
Practice Address - Country:US
Practice Address - Phone:480-397-6010
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GRAND CANYON HOME CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-07-30
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care ProviderGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ568006Medicaid