Basic Information
| Provider Information | |||||||||
| NPI: | 1043303753 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALLIANCE HOSPICE LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CRESCENT HOSPICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 FAULCONER DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTESVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229035089 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4349779711 | ||||||||
| FaxNumber: | 4349779715 | ||||||||
| Practice Location | |||||||||
| Address1: | 3475 RIVERWATCH PARKWAY | ||||||||
| Address2: | SUITE 320 | ||||||||
| City: | MARTINEZ | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309070000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7064472461 | ||||||||
| FaxNumber: | 7064472465 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 03/02/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HUNTER | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | BRADLEY | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 4349779711 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | 11-1631 | GA | Y | Agencies | Hospice Care, Community Based |
ID Information
| ID | Type | State | Issuer | Description | 041396802A | 05 | GA | MEDICAID |