Provider Demographics
NPI:1073859237
Name:SACRED ONE HOSPICE, INC.
Entity Type:Organization
Organization Name:SACRED ONE HOSPICE, INC.
Other - Org Name:SACRED HEART HOSPICE INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MAX
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:REGISTERED NURSE
Authorized Official - Phone:562-841-0714
Mailing Address - Street 1:3699 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 870
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90010-2718
Mailing Address - Country:US
Mailing Address - Phone:213-368-0254
Mailing Address - Fax:213-368-0258
Practice Address - Street 1:3699 WILSHIRE BLVD
Practice Address - Street 2:SUITE 870
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90010-2718
Practice Address - Country:US
Practice Address - Phone:213-368-0254
Practice Address - Fax:213-368-0258
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-17
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA550000246251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA551528Medicare Oscar/Certification