Basic Information
| Provider Information | |||||||||
| NPI: | 1194028688 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HEARTLITE HOSPICE ELLIJAY, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 800 W. ROOSEVELT ROAD | ||||||||
| Address2: | SUITE C-206 | ||||||||
| City: | GLEN ELLYN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601375851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6309420100 | ||||||||
| FaxNumber: | 2565322398 | ||||||||
| Practice Location | |||||||||
| Address1: | 163 DALTON STREET | ||||||||
| Address2: | |||||||||
| City: | EAST ELLIJAY | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7066357001 | ||||||||
| FaxNumber: | 7066357003 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2010 | ||||||||
| LastUpdateDate: | 01/29/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DANEKAS | ||||||||
| AuthorizedOfficialFirstName: | CURTIS | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6309420100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CPA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | 061-0343-H | GA | Y | Agencies | Hospice Care, Community Based |
No ID Information.