Provider Demographics
NPI:1790406148
Name:AT HOME PALLIATIVE CARE, LLC
Entity Type:Organization
Organization Name:AT HOME PALLIATIVE CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:CISZEK
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:478-290-0677
Mailing Address - Street 1:463688 STATE ROAD 200, STE 1
Mailing Address - Street 2:#364
Mailing Address - City:YULEE
Mailing Address - State:FL
Mailing Address - Zip Code:32097
Mailing Address - Country:US
Mailing Address - Phone:478-290-0677
Mailing Address - Fax:
Practice Address - Street 1:10752 DEERWOOD PARK BLVD STE 100
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-4846
Practice Address - Country:US
Practice Address - Phone:478-290-0677
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-05
Last Update Date:2022-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative MedicineGroup - Single Specialty