Provider Demographics
NPI:1457338758
Name:BOTHWELL REGIONAL HEALTH CENTER HOSPICE
Entity Type:Organization
Organization Name:BOTHWELL REGIONAL HEALTH CENTER HOSPICE
Other - Org Name:BOTHWELL REGIONAL HEALTH CENTER HOSPICE
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:DAWES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-827-9481
Mailing Address - Street 1:601 E 14TH STREET
Mailing Address - Street 2:
Mailing Address - City:SEDALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65301-1706
Mailing Address - Country:US
Mailing Address - Phone:660-829-2700
Mailing Address - Fax:660-829-1740
Practice Address - Street 1:3143 W BROADWAY BLVD
Practice Address - Street 2:
Practice Address - City:SEDALIA
Practice Address - State:MO
Practice Address - Zip Code:65301-2116
Practice Address - Country:US
Practice Address - Phone:660-829-2700
Practice Address - Fax:660-829-1740
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-28
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO00010642251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO820157808Medicaid
261532Medicare Oscar/Certification