Basic Information
| Provider Information | |||||||||
| NPI: | 1467409219 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | YRMC HOSPICE | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | YAVAPAI COMMUNITY HOSPITAL ASSOCIATION | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3262 N WINDSONG DR | ||||||||
| Address2: | |||||||||
| City: | PRESCOTT VALLEY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 863142255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287595900 | ||||||||
| FaxNumber: | 9287595982 | ||||||||
| Practice Location | |||||||||
| Address1: | 3262 N WINDSONG DR | ||||||||
| Address2: | |||||||||
| City: | PRESCOTT VALLEY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 863142255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287595900 | ||||||||
| FaxNumber: | 9287595982 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BRISTOL | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
| AuthorizedOfficialMiddleName: | O | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9287715691 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | HSPC0008 | AZ | Y | Agencies | Hospice Care, Community Based |
ID Information
| ID | Type | State | Issuer | Description | 179467 | 05 | AZ | MEDICAID | AZ0700600 | 01 | AZ | BLUE CROSS PROVIDER | OTHER |