Basic Information
| Provider Information | |||||||||
| NPI: | 1265433247 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ODYSSEY HEALTHCARE OPERATING A LP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | KINDRED HOSPICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 655 BRAWLEY SCHOOL RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | MOORESVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281179601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046642876 | ||||||||
| FaxNumber: | 7046641306 | ||||||||
| Practice Location | |||||||||
| Address1: | 444 REGENCY PARKWAY DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681143779 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023970990 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2005 | ||||||||
| LastUpdateDate: | 01/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | COMBS | ||||||||
| AuthorizedOfficialFirstName: | JANET | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP OF REGULATORY AND LICENSURE | ||||||||
| AuthorizedOfficialTelephone: | 7046642876 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | Y | Agencies | Hospice Care, Community Based |
ID Information
| ID | Type | State | Issuer | Description | 0610261 | 05 | IA | MEDICAID | 10025293100 | 05 | NE | MEDICAID | 10025019900 | 05 | NE | MEDICAID | 10025033000 | 05 | NE | MEDICAID | 10025142800 | 05 | NE | MEDICAID | 10025158200 | 05 | NE | MEDICAID | 10025032900 | 05 | NE | MEDICAID | 10025077800 | 05 | NE | MEDICAID | 10025233000 | 05 | NE | MEDICAID | 10025019500 | 05 | NE | MEDICAID | 10025020000 | 05 | NE | MEDICAID | 10025020100 | 05 | NE | MEDICAID | 10025212000 | 05 | NE | MEDICAID | 10025272200 | 05 | NE | MEDICAID | 10025019700 | 05 | NE | MEDICAID | 10025019800 | 05 | NE | MEDICAID | 10025158100 | 05 | NE | MEDICAID | 10025272300 | 05 | NE | MEDICAID | 10025196100 | 05 | NE | MEDICAID |