Basic Information
| Provider Information | |||||||||
| NPI: | 1962658369 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MAYERS MEMORIAL HOSPITAL DISTRICT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | INTERMOUNTAIN HOSPICE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 459 | ||||||||
| Address2: | |||||||||
| City: | FALL RIVER MILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 96028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5303365511 | ||||||||
| FaxNumber: | 5303366199 | ||||||||
| Practice Location | |||||||||
| Address1: | 43563 STATE HIGHWAY 299 E | ||||||||
| Address2: | |||||||||
| City: | FALL RIVER MILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960289787 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5303365511 | ||||||||
| FaxNumber: | 5303366996 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2008 | ||||||||
| LastUpdateDate: | 05/23/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | REES | ||||||||
| AuthorizedOfficialFirstName: | MATT | ||||||||
| AuthorizedOfficialMiddleName: | ANN | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5303365511 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MAYERS MEMORIAL HOSPITAL DISTRICT | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | 230000021 | CA | Y | Agencies | Hospice Care, Community Based |
ID Information
| ID | Type | State | Issuer | Description | HPC01738F | 01 | CA | MEDI-CAL HOSPICE | OTHER |