1568710358 NPI number — BRISTOL HOSPICE - PATHWAYS LLC

Table of content: (NPI 1568710358)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568710358 NPI number — BRISTOL HOSPICE - PATHWAYS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRISTOL HOSPICE - PATHWAYS LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
BRISTOL HOSPICE - NORTH CENTRAL TEXAS
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1568710358
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/29/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
206 N 2100 W
Provider Second Line Business Mailing Address:
SUITE 202
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84116-4740
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-325-0175
Provider Business Mailing Address Fax Number:
801-478-3533

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1905 N HIGHWAY 77 STE 220
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAXAHACHIE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75165-7916
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-923-2436
Provider Business Practice Location Address Fax Number:
972-923-0043
Provider Enumeration Date:
08/27/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MAURICIO
Authorized Official First Name:
ALEX
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT CEO
Authorized Official Telephone Number:
801-325-0175

Provider Taxonomy Codes

  • Taxonomy code: 251G00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 001025673 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".