Provider Demographics
NPI:1033191440
Name:HIGH DESERT HOSPICE LLC
Entity Type:Organization
Organization Name:HIGH DESERT HOSPICE LLC
Other - Org Name:BRISTOL HOSPICE - KLAMATH FALLS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:HYRUM
Authorized Official - Middle Name:A
Authorized Official - Last Name:KIRTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-325-0175
Mailing Address - Street 1:206 N 2100 W STE 202
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84116-4741
Mailing Address - Country:US
Mailing Address - Phone:801-325-0175
Mailing Address - Fax:801-478-3533
Practice Address - Street 1:2210 SHALLOCK AVENUE
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-4290
Practice Address - Country:US
Practice Address - Phone:541-882-1636
Practice Address - Fax:541-882-1799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-19
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251G00000X
OR251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR028060Medicaid
OR028060Medicaid