Provider Demographics
NPI:1437158821
Name:CENTERWELL CERTIFIED HEALTHCARE CORP
Entity type:Organization
Organization Name:CENTERWELL CERTIFIED HEALTHCARE CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED SIGNATORY
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-445-2522
Mailing Address - Street 1:6330 SPRINT PKWY STE 300
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66211-1157
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3107 CLEARWATER DR
Practice Address - Street 2:SUITE A
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-7167
Practice Address - Country:US
Practice Address - Phone:928-445-2522
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-18
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZHHA0186251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
037139Medicare Oscar/Certification