Provider Demographics
NPI:1366440083
Name:CHARLES WM. LEIGHTON JR HOSPICE, INC.
Entity Type:Organization
Organization Name:CHARLES WM. LEIGHTON JR HOSPICE, INC.
Other - Org Name:CHARLES WM. LEIGHTON HOSPICE, INC.
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:D
Authorized Official - Last Name:DOUGLAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-384-5878
Mailing Address - Street 1:P.O. BOX 115
Mailing Address - Street 2:
Mailing Address - City:WILLCOX
Mailing Address - State:AZ
Mailing Address - Zip Code:85644
Mailing Address - Country:US
Mailing Address - Phone:520-384-5878
Mailing Address - Fax:520-384-4127
Practice Address - Street 1:524 WEST MALEY PLACE
Practice Address - Street 2:
Practice Address - City:WILLCOX
Practice Address - State:AZ
Practice Address - Zip Code:85643
Practice Address - Country:US
Practice Address - Phone:520-384-5878
Practice Address - Fax:520-384-4127
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZHSPC-2902251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ03-1551Medicare ID - Type UnspecifiedHOSPICE