Provider Demographics
NPI:1275513129
Name:HOSPICE PEACHTREE LLC
Entity Type:Organization
Organization Name:HOSPICE PEACHTREE LLC
Other - Org Name:PEACHTREE HOSPICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:PETRUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-494-0100
Mailing Address - Street 1:2910 JENNY LIND RD
Mailing Address - Street 2:#4
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72901-6735
Mailing Address - Country:US
Mailing Address - Phone:479-494-0100
Mailing Address - Fax:
Practice Address - Street 1:2910 JENNY LIND RD
Practice Address - Street 2:#4
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72901-6735
Practice Address - Country:US
Practice Address - Phone:479-494-0100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-18
Last Update Date:2010-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR141698747Medicaid
AR141698747Medicaid