Provider Demographics
NPI:1720150212
Name:PROVIDENCE HOSPICE, INC.
Entity Type:Organization
Organization Name:PROVIDENCE HOSPICE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICE
Authorized Official - Prefix:
Authorized Official - First Name:IAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:ASH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-644-5134
Mailing Address - Street 1:100 CORPORATE CENTER DRIVE
Mailing Address - Street 2:LOWER LEVEL
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-7244
Mailing Address - Country:US
Mailing Address - Phone:678-284-9385
Mailing Address - Fax:678-284-9391
Practice Address - Street 1:100 CORPORATE CENTER DRIVE
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-7244
Practice Address - Country:US
Practice Address - Phone:678-284-9385
Practice Address - Fax:678-284-9391
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2010-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA075-0253-H251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA015893264AMedicaid
GA111646Medicare PIN
GA015893264AMedicaid