Provider Demographics
NPI:1548218738
Name:PROVIDENCE HOSPICE, LLC
Entity Type:Organization
Organization Name:PROVIDENCE HOSPICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:E
Authorized Official - Last Name:KEYES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-956-9755
Mailing Address - Street 1:13 NORTHTOWN DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-3047
Mailing Address - Country:US
Mailing Address - Phone:601-956-9755
Mailing Address - Fax:601-956-0743
Practice Address - Street 1:13 NORTHTOWN DR
Practice Address - Street 2:SUITE 220
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-3047
Practice Address - Country:US
Practice Address - Phone:601-956-9755
Practice Address - Fax:601-956-0743
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-04
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS090251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08734861Medicaid
MS251586Medicare Oscar/Certification