1134123011 NPI number — HOSPICE

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134123011 NPI number — HOSPICE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HOSPICE
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:
Provider Other Organization Name Type Code:
6
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:
1134123011
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/09/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1150
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OTTUMWA
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52501-7150
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
641-682-0684
Provider Business Mailing Address Fax Number:
641-684-9209

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
927 PENNSYLVANIA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OTTUMWA
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52501-2138
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
641-682-0684
Provider Business Practice Location Address Fax Number:
641-684-9209
Provider Enumeration Date:
06/09/2005

Additional Information

Authorized Official

Authorized Official Last Name:
ANDERSON
Authorized Official First Name:
SUZANNE
Authorized Official Middle Name:
M
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
641-682-0684

Provider Taxonomy Codes

  • Taxonomy code: 315D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251G00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0615138 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 61513 . This is a "WELLMARK BLUE CROSS AND BLUE SHIELD OF IOWA" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".




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