Basic Information
Provider Information | |||||||||
NPI: | 1528344553 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SAINT JUDE HOSPICE, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SAINT JUDE HOSPICE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 13375 UNIVERSITY AVE | ||||||||
Address2: | SUITE 200 | ||||||||
City: | CLIVE | ||||||||
State: | IA | ||||||||
PostalCode: | 503258261 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5152219155 | ||||||||
FaxNumber: | 5152219157 | ||||||||
Practice Location | |||||||||
Address1: | 1660 S ALMA SCHOOL RD | ||||||||
Address2: | SUITE 223 | ||||||||
City: | MESA | ||||||||
State: | AZ | ||||||||
PostalCode: | 852103069 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4808218338 | ||||||||
FaxNumber: | 4808972601 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/21/2011 | ||||||||
LastUpdateDate: | 04/23/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HOGAN | ||||||||
AuthorizedOfficialFirstName: | KATHLEEN | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | CONTROLLER | ||||||||
AuthorizedOfficialTelephone: | 5152219155 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | HSPC4820 | AZ | Y |   | Agencies | Hospice Care, Community Based |   |
No ID Information.