Provider Demographics
NPI:1033366794
Name:LESTER DIERKSEN MEMORIAL HOSPICE, LLC
Entity Type:Organization
Organization Name:LESTER DIERKSEN MEMORIAL HOSPICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:HUNTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-977-9711
Mailing Address - Street 1:500 FAULCONER DR STE 200
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22903-5089
Mailing Address - Country:US
Mailing Address - Phone:434-977-9711
Mailing Address - Fax:
Practice Address - Street 1:2504 ALEXANDER DR
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-7175
Practice Address - Country:US
Practice Address - Phone:870-932-2880
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-25
Last Update Date:2021-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR4487251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR041575Medicare Oscar/Certification