Provider Demographics
NPI:1215543434
Name:COUNTRY CLUB HOSPICE, INC.
Entity Type:Organization
Organization Name:COUNTRY CLUB HOSPICE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:GABRIELYAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:747-200-4175
Mailing Address - Street 1:3089 N LIMA ST STE D
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91504-2013
Mailing Address - Country:US
Mailing Address - Phone:747-200-4175
Mailing Address - Fax:747-273-0558
Practice Address - Street 1:3089 N LIMA ST STE D
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91504-2013
Practice Address - Country:US
Practice Address - Phone:747-200-4175
Practice Address - Fax:747-273-0558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-22
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based