Provider Demographics
NPI:1629405485
Name:HARBOR LIGHT HOSPICE OF MISSOURI LLC
Entity Type:Organization
Organization Name:HARBOR LIGHT HOSPICE OF MISSOURI LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:S
Authorized Official - Last Name:THOME
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:630-942-0100
Mailing Address - Street 1:800 ROOSEVELT RD STE C206
Mailing Address - Street 2:SUITE C-206
Mailing Address - City:GLEN ELLYN
Mailing Address - State:IL
Mailing Address - Zip Code:60137-5851
Mailing Address - Country:US
Mailing Address - Phone:630-942-0100
Mailing Address - Fax:
Practice Address - Street 1:2258 SCHUETZ RD
Practice Address - Street 2:SUITE 116
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63146-3423
Practice Address - Country:US
Practice Address - Phone:314-692-7211
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-10
Last Update Date:2014-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO261628Medicare Oscar/Certification