Provider Demographics
NPI:1346544848
Name:WISTERIA HOSPICE, INC.
Entity Type:Organization
Organization Name:WISTERIA HOSPICE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:
Authorized Official - Last Name:RAGO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-682-1676
Mailing Address - Street 1:4182 N VIKING WAY
Mailing Address - Street 2:STE 216
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90808-1491
Mailing Address - Country:US
Mailing Address - Phone:562-682-1678
Mailing Address - Fax:562-431-9967
Practice Address - Street 1:4182 N VIKING WAY
Practice Address - Street 2:STE 216
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90808-1491
Practice Address - Country:US
Practice Address - Phone:562-431-3308
Practice Address - Fax:562-431-9967
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-27
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251G00000X
CA251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based