Basic Information
| Provider Information | |||||||||
| NPI: | 1376750398 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | 365 HOSPICE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 119 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CARROLLTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 157220477 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8144194901 | ||||||||
| FaxNumber: | 8144194902 | ||||||||
| Practice Location | |||||||||
| Address1: | 220 REGENT CT STE E2 | ||||||||
| Address2: | |||||||||
| City: | STATE COLLEGE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 168017969 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8149465017 | ||||||||
| FaxNumber: | 8143089947 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2007 | ||||||||
| LastUpdateDate: | 10/26/2022 | ||||||||
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| AuthorizedOfficialLastName: | REZK | ||||||||
| AuthorizedOfficialFirstName: | JONATHAN | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8149465017 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | Y | Agencies | Hospice Care, Community Based |
ID Information
| ID | Type | State | Issuer | Description | 16911601 | 01 | PA | STATE OF PENNSYLVANIA | OTHER | 1020513330001 | 05 | PA | MEDICAID |