Provider Demographics
NPI:1629214515
Name:MARY T HOSPICE
Entity Type:Organization
Organization Name:MARY T HOSPICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND STOCKHOLDER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY T
Authorized Official - Middle Name:
Authorized Official - Last Name:TJOSVOLD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-754-2505
Mailing Address - Street 1:1555 118TH LN NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55448-7579
Mailing Address - Country:US
Mailing Address - Phone:763-754-2505
Mailing Address - Fax:763-755-3631
Practice Address - Street 1:1555 118TH LN NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55448-7579
Practice Address - Country:US
Practice Address - Phone:763-754-2505
Practice Address - Fax:763-862-5472
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARY T. ASSOCIATES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-12-23
Last Update Date:2008-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN342612251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN342612OtherHOSPICE, STATE LICENSE