Provider Demographics
NPI:1669475513
Name:CROSS TIMBERS HOSPICE, INC
Entity Type:Organization
Organization Name:CROSS TIMBERS HOSPICE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:DODGE
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:580-223-0655
Mailing Address - Street 1:207 C ST NW
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-6216
Mailing Address - Country:US
Mailing Address - Phone:580-223-0655
Mailing Address - Fax:580-223-3267
Practice Address - Street 1:207 C ST NW
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-6216
Practice Address - Country:US
Practice Address - Phone:580-223-0655
Practice Address - Fax:580-223-3267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-24
Last Update Date:2010-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4056251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK371547Medicare ID - Type Unspecified