Provider Demographics
NPI:1235120197
Name:LIFEPATH HOSPICE AND PALLIATIVE CARE INC
Entity Type:Organization
Organization Name:LIFEPATH HOSPICE AND PALLIATIVE CARE INC
Other - Org Name:GOOD SHEPHERD HOSPICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:H
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-871-8111
Mailing Address - Street 1:12973 N TELECOM PKWY
Mailing Address - Street 2:STE 100
Mailing Address - City:TEMPLE TERRACE
Mailing Address - State:FL
Mailing Address - Zip Code:33637-0907
Mailing Address - Country:US
Mailing Address - Phone:813-871-8111
Mailing Address - Fax:
Practice Address - Street 1:12973 N TELECOM PKWY
Practice Address - Street 2:STE 100
Practice Address - City:TEMPLE TERRACE
Practice Address - State:FL
Practice Address - Zip Code:33637-0907
Practice Address - Country:US
Practice Address - Phone:813-871-8111
Practice Address - Fax:813-975-9621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101507Medicare ID - Type Unspecified