1649482621 NPI number — COMFORTBROOK HOSPICE, LLC

Table of content: (NPI 1649482621)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649482621 NPI number — COMFORTBROOK HOSPICE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMFORTBROOK HOSPICE, 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:
GRACE HOSPICE
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:
1649482621
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/27/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 99278
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TROY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48099-9278
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-824-6609
Provider Business Mailing Address Fax Number:
855-618-6655

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1900 INDIAN WOOD CIR STE 202A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MAUMEE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43537-4039
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
567-218-2075
Provider Business Practice Location Address Fax Number:
877-473-8167
Provider Enumeration Date:
05/04/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CHANCE
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO/AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
248-824-6004

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: 0193HSP . This is a "STATE OF OHIO HOSPICE LICENSE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2889674 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: FCY.022229050-12 . This is a "OH TDDD" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".