Provider Demographics
NPI:1093118671
Name:DESERT PANTHEON LLC
Entity Type:Organization
Organization Name:DESERT PANTHEON LLC
Other - Org Name:MISSION TRAIL HOSPICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NATALIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ZIMNEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-509-5276
Mailing Address - Street 1:1724B TEXAS AVE
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79901-1810
Mailing Address - Country:US
Mailing Address - Phone:915-800-1111
Mailing Address - Fax:281-208-0179
Practice Address - Street 1:1724B TEXAS AVE
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79901-1810
Practice Address - Country:US
Practice Address - Phone:915-800-1111
Practice Address - Fax:915-288-2072
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-26
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX000000Medicaid