Provider Demographics
NPI:1497031421
Name:AVALON HOSPICE, LLC
Entity Type:Organization
Organization Name:AVALON HOSPICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:RAYMOND
Authorized Official - Last Name:BRYAN
Authorized Official - Suffix:
Authorized Official - Credentials:MOT
Authorized Official - Phone:208-419-0896
Mailing Address - Street 1:403 1ST ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-3928
Mailing Address - Country:US
Mailing Address - Phone:208-419-0896
Mailing Address - Fax:208-419-0974
Practice Address - Street 1:403 1ST ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-3928
Practice Address - Country:US
Practice Address - Phone:208-419-0896
Practice Address - Fax:208-419-0974
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-21
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based