Copper State Home Health, LLC
Organization Active NPI Home Health Agency · Globe, AZ
NPI 1972999100 · NPPES record last updated Jul 21, 2022
Key facts
- NPI
- 1972999100
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Home Health Agency 251E00000X
- Legal business name
- COPPER STATE HOME HEALTH, LLC
- Practice address
- 996 N Broad St Ste 7
Globe, AZ 85501-2300 - Phone
- (928) 200-9708
- Fax
- (602) 926-2423
- NPI assigned
- Apr 14, 2015
- Organization subpart
- No
Authorized official
- Name
- Mellisa Marie Taylor, RN
- Title
- Don Administrator
- Phone
- (928) 200-9708
Affiliated clinicians 4
-
Holly Elizabeth Rooney, M.D.
Medicare Care Compare: Home health agency
- Listed as
- Copper State Home Health, LLC
- Ownership
- Proprietary
- Certified
- Mar 22, 2018
- Medicare certification status
- Active
- Services
- Nursing, Home health aide, Physical therapy
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 03D2135114 | Copper State Home Health LLC | Certificate of waiver | Aug 14, 2027 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in AZ
Home health agency certification: CCN 037476
- Legal name
- COPPER STATE HOME HEALTH, LLC
- Certification status
- Active
- Provider type (POS)
- Home health agency
- Participating since
- Mar 22, 2018
- Last certification
- Feb 17, 2021
- Ownership / control type
- Proprietary
- Organization structure
- LLC · Proprietary
- Enrollment address
- 996 N Broad St
Ste 7
Globe, AZ 85501-2300
All disclosed owners & managing parties 2
| Name | Role | Since | Share |
|---|---|---|---|
| Mellisa Marie Taylor |
5% Or Greater Direct Ownership Interest |
Mar 15, 2015 | 50% |
| W-2 Managing Employee | Nov 1, 2022 | 50% | |
| Clinton Taylor |
5% Or Greater Direct Ownership Interest |
Mar 15, 2015 | 50% |
| W-2 Managing Employee | Nov 1, 2022 | 50% |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20171006002815 | AZ | Part a Provider - Home Health Agency | 4880969468 | Practice locations: Globe, AZ |
National Provider Directory
Locations
996 N Broad St
Ste 7
Globe, AZ 85501
Phone (928) 200-9708
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Home Health Agency | 251E00000X | AZ | Yes |
Addresses
Primary practice location
996 N Broad St Ste 7
Globe, AZ 85501-2300
Mailing address
996 N Broad St Ste 7
Globe, AZ 85501-2300
Phone (928) 200-9708
Other names
- Copper State Home Health
Other providers in Globe, AZ
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jul 21, 2022. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.