Basic Information
| Provider Information | |||||||||
| NPI: | 1558305334 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HOSPICE ADVANTAGE, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HOSPICE ADVANTAGE, INC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10 CADILLAC DRIVE | ||||||||
| Address2: | SUITE 10 | ||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370271001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153777022 | ||||||||
| FaxNumber: | 6153734457 | ||||||||
| Practice Location | |||||||||
| Address1: | 3235 SATELLITE BLVD STE 290 | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300968689 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704498142 | ||||||||
| FaxNumber: | 7704498143 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 12/11/2020 | ||||||||
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| AuthorizedOfficialLastName: | ADKINS | ||||||||
| AuthorizedOfficialFirstName: | RUSSELL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SVP GENERAL COUNSEL | ||||||||
| AuthorizedOfficialTelephone: | 6153095668 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | 0670266H | GA | Y | Agencies | Hospice Care, Community Based |
ID Information
| ID | Type | State | Issuer | Description | 361284326A | 05 | GA | MEDICAID |