1841696911 NPI number — EVERGREEN HOSPICE AND PALLIATIVE CARE

Table of content: (NPI 1841696911)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841696911 NPI number — EVERGREEN HOSPICE AND PALLIATIVE CARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EVERGREEN HOSPICE AND PALLIATIVE CARE
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:
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:
1841696911
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/17/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2146
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PINETOP
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85935-2146
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-218-0811
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
454 W WHITE MOUNTAIN BLVD
Provider Second Line Business Practice Location Address:
SUITE 7
Provider Business Practice Location Address City Name:
LAKESIDE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85929-6663
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-549-1905
Provider Business Practice Location Address Fax Number:
888-432-7480
Provider Enumeration Date:
11/17/2014

Additional Information

Authorized Official

Authorized Official Last Name:
BAUDER
Authorized Official First Name:
MARC
Authorized Official Middle Name:
ALAN
Authorized Official Title or Position:
CHIEF MEDICAL DIRECTOR
Authorized Official Telephone Number:
602-218-0811

Provider Taxonomy Codes

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

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





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