Provider Demographics
NPI:1033165352
Name:DESERT OASIS HOSPICE LLC
Entity Type:Organization
Organization Name:DESERT OASIS HOSPICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:GORDON
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-424-4204
Mailing Address - Street 1:5147 N 45TH PL
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-1704
Mailing Address - Country:US
Mailing Address - Phone:602-505-1018
Mailing Address - Fax:
Practice Address - Street 1:5147 N 45TH PL
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85018-1704
Practice Address - Country:US
Practice Address - Phone:602-505-1018
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZHSPC3868251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0911060OtherBCBS
AZ031568Medicare ID - Type UnspecifiedHOSPICE
AZ108714Medicaid