Provider Demographics
NPI:1689716797
Name:CHARTER HOSPICE OF COLTON, LLC
Entity Type:Organization
Organization Name:CHARTER HOSPICE OF COLTON, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ATTORNEY
Authorized Official - Prefix:
Authorized Official - First Name:SYLVIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOAL
Authorized Official - Suffix:
Authorized Official - Credentials:ESQ
Authorized Official - Phone:866-669-1686
Mailing Address - Street 1:1012 EAST COOLEY DRIVE
Mailing Address - Street 2:SUITE G
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-3959
Mailing Address - Country:US
Mailing Address - Phone:909-825-2969
Mailing Address - Fax:909-825-8751
Practice Address - Street 1:1007 E COOLEY DR STE 100
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-3901
Practice Address - Country:US
Practice Address - Phone:909-825-2969
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA550000224251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA05-1799Medicare ID - Type Unspecified