Provider Demographics
NPI:1770572737
Name:FRONTIER HOSPICE, LLC
Entity type:Organization
Organization Name:FRONTIER HOSPICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:D
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-544-5891
Mailing Address - Street 1:4718 N ELIZABETH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-2079
Mailing Address - Country:US
Mailing Address - Phone:719-544-5891
Mailing Address - Fax:719-544-5895
Practice Address - Street 1:4718 N ELIZABETH ST
Practice Address - Street 2:SUITE A
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-2079
Practice Address - Country:US
Practice Address - Phone:719-544-5891
Practice Address - Fax:719-544-5895
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-20
Last Update Date:2013-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO17E478251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO16889355Medicaid
CO16889355Medicaid