Basic Information
Provider Information | |||||||||
NPI: | 1760467575 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HOSPICE FAMILY CARE, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 655 BRAWLEY SCHOOL RD | ||||||||
Address2: | SUITE 200 | ||||||||
City: | MOORESVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 281179125 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7046642876 | ||||||||
FaxNumber: | 7046641306 | ||||||||
Practice Location | |||||||||
Address1: | 6300 E EL DORADO PLZ | ||||||||
Address2: | A-100 | ||||||||
City: | TUCSON | ||||||||
State: | AZ | ||||||||
PostalCode: | 857154642 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5207909299 | ||||||||
FaxNumber: | 5207909279 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/14/2005 | ||||||||
LastUpdateDate: | 01/15/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KLEBERG | ||||||||
AuthorizedOfficialFirstName: | JESSICA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VP OF LEGAL AFFAIRS | ||||||||
AuthorizedOfficialTelephone: | 7046642876 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | HSPC0030 | AZ | Y |   | Agencies | Hospice Care, Community Based |   |
ID Information
ID | Type | State | Issuer | Description | 199457 | 05 | AZ |   | MEDICAID | F05222 | 01 | AZ | PHOENIX HEALTH PLAN | OTHER | AZ0700420 | 01 | AZ | BC/BS OF ARIZONA | OTHER | IZ0241 | 01 |   | HEALTH NET | OTHER |