Provider Demographics
NPI:1417062274
Name:CREEKSIDE HOSPICE INC.
Entity Type:Organization
Organization Name:CREEKSIDE HOSPICE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:H
Authorized Official - Last Name:BREINHOLT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-486-2348
Mailing Address - Street 1:PO BOX 65788
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84165-0788
Mailing Address - Country:US
Mailing Address - Phone:801-486-2348
Mailing Address - Fax:801-466-8961
Practice Address - Street 1:1246 YELLOWSTONE AVE STE C5
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4373
Practice Address - Country:US
Practice Address - Phone:208-637-1100
Practice Address - Fax:208-637-1102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
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
ID131550Medicare ID - Type Unspecified