Provider Demographics
NPI:1730125949
Name:ETERNITY HOSPICE INC
Entity Type:Organization
Organization Name:ETERNITY HOSPICE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:L
Authorized Official - Last Name:FAIRLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-517-0025
Mailing Address - Street 1:PO BOX 686
Mailing Address - Street 2:
Mailing Address - City:INDIANOLA
Mailing Address - State:MS
Mailing Address - Zip Code:38751-0686
Mailing Address - Country:US
Mailing Address - Phone:662-887-3380
Mailing Address - Fax:662-887-3739
Practice Address - Street 1:417 HIGHWAY 82 E STE 23
Practice Address - Street 2:
Practice Address - City:INDIANOLA
Practice Address - State:MS
Practice Address - Zip Code:38751-2315
Practice Address - Country:US
Practice Address - Phone:662-887-3380
Practice Address - Fax:662-887-3739
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-22
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS093251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09628359Medicaid
MS251587Medicare Oscar/Certification