Basic Information
| Provider Information | |||||||||
| NPI: | 1417130170 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ADENA HOSPICE, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | ADENA HOSPICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2077 WESTERN AVE | ||||||||
| Address2: | |||||||||
| City: | CHILLICOTHE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456017506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7407794663 | ||||||||
| FaxNumber: | 7407794674 | ||||||||
| Practice Location | |||||||||
| Address1: | 2077 WESTERN AVE | ||||||||
| Address2: | |||||||||
| City: | CHILLICOTHE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456017506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7407794663 | ||||||||
| FaxNumber: | 7407794674 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/17/2007 | ||||||||
| LastUpdateDate: | 05/26/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CARLSON | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7407797582 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | Y | Agencies | Hospice Care, Community Based |
ID Information
| ID | Type | State | Issuer | Description | 0062805 | 05 | OH | MEDICAID |