Provider Demographics
NPI:1558663872
Name:BRISTOL HOSPICE - GEORGIA LLC
Entity Type:Organization
Organization Name:BRISTOL HOSPICE - GEORGIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:ALEX
Authorized Official - Middle Name:
Authorized Official - Last Name:MAURICIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-325-0175
Mailing Address - Street 1:206 N 2100 W STE 202
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84116-4741
Mailing Address - Country:US
Mailing Address - Phone:801-325-0175
Mailing Address - Fax:
Practice Address - Street 1:2849 PACES FERRY RD SE STE 380
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30339-3769
Practice Address - Country:US
Practice Address - Phone:770-434-9530
Practice Address - Fax:770-434-9529
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRISTOL HOSPICE, L.L.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-11-18
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003119387AMedicaid