Provider Demographics
NPI:1336916469
Name:BRISTOL HOSPICE- BANGOR, LLC
Entity Type:Organization
Organization Name:BRISTOL HOSPICE- BANGOR, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
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 STE 202
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84116-4741
Mailing Address - Country:US
Mailing Address - Phone:801-325-0175
Mailing Address - Fax:
Practice Address - Street 1:700 MAIN ST STE 3
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-6800
Practice Address - Country:US
Practice Address - Phone:801-325-0175
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-08
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based