Provider Demographics
NPI:1679011720
Name:BRISTOL HOSPICE - MIAMI DADE, LLC
Entity Type:Organization
Organization Name:BRISTOL HOSPICE - MIAMI DADE, LLC
Other - Org Name:BRISTOL HOSPICE - NORTH MIAMI
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO AND PRESIDENT
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
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84116-4740
Mailing Address - Country:US
Mailing Address - Phone:801-325-0175
Mailing Address - Fax:801-478-3588
Practice Address - Street 1:5201 BLUE LAGOON DR
Practice Address - Street 2:SUITE 570
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33126-2064
Practice Address - Country:US
Practice Address - Phone:801-656-2769
Practice Address - Fax:501-478-3588
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRISTOL HOSPICE, L.L.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-02-09
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL105421900Medicaid