Provider Demographics
NPI:1609900364
Name:OPTUM PALLIATIVE AND HOSPICE CARE, INC
Entity Type:Organization
Organization Name:OPTUM PALLIATIVE AND HOSPICE CARE, INC
Other - Org Name:EVERCARE HOSPICE, INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:O
Authorized Official - Last Name:ENDERLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-221-0793
Mailing Address - Street 1:PO BOX 15645
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89114-5645
Mailing Address - Country:US
Mailing Address - Phone:215-902-8241
Mailing Address - Fax:215-902-8809
Practice Address - Street 1:4875 RIVERSIDE DR STE 104
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-1149
Practice Address - Country:US
Practice Address - Phone:478-812-9299
Practice Address - Fax:478-912-9270
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COLLABORATIVE CARE HOLDINGS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-15
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251G00000X
GA0011-0296-H251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
111671Medicare PIN