Provider Demographics
NPI:1386628931
Name:HOSPICE OF FAYETTE COUNTY INC.
Entity Type:Organization
Organization Name:HOSPICE OF FAYETTE COUNTY INC.
Other - Org Name:HOSPICE OF FAYETTE COUNTY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MISSI
Authorized Official - Middle Name:
Authorized Official - Last Name:KNISLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-474-2441
Mailing Address - Street 1:222 NORTH OAKLAND AVENUE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON COURT HOUSE
Mailing Address - State:OH
Mailing Address - Zip Code:43160-0849
Mailing Address - Country:US
Mailing Address - Phone:740-335-0149
Mailing Address - Fax:740-335-3489
Practice Address - Street 1:222 N OAKLAND AVE
Practice Address - Street 2:
Practice Address - City:WASHINGTON COURT HOUSE
Practice Address - State:OH
Practice Address - Zip Code:43160-1234
Practice Address - Country:US
Practice Address - Phone:740-335-0149
Practice Address - Fax:740-335-3489
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-06
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0011-HSP251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0819716Medicaid
OH000000156813OtherANTEHM BC/BS
OH=========OtherFEDERAL TAX ID
OH361553Medicare ID - Type UnspecifiedHOSPICE
HI0819716Medicaid