Provider Demographics
NPI:1467481101
Name:ETERNITY HOSPICE INC.
Entity Type:Organization
Organization Name:ETERNITY HOSPICE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:FAIRLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-517-0025
Mailing Address - Street 1:12000 MOBILE AVE
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-3113
Mailing Address - Country:US
Mailing Address - Phone:228-832-7211
Mailing Address - Fax:228-832-7213
Practice Address - Street 1:12000 MOBILE AVE
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-3113
Practice Address - Country:US
Practice Address - Phone:228-832-7211
Practice Address - Fax:228-832-7213
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-03
Last Update Date:2009-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS251617251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS251634Medicare Oscar/Certification