Provider Demographics
NPI:1811987357
Name:AVALON HOSPICE
Entity type:Organization
Organization Name:AVALON HOSPICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACTICTIONER
Authorized Official - Prefix:
Authorized Official - First Name:REEANN
Authorized Official - Middle Name:
Authorized Official - Last Name:SLAGOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-733-7250
Mailing Address - Street 1:2360 STONEBRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-5406
Mailing Address - Country:US
Mailing Address - Phone:810-733-7250
Mailing Address - Fax:810-733-8424
Practice Address - Street 1:2360 STONEBRIDGE DR
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-5406
Practice Address - Country:US
Practice Address - Phone:810-733-7250
Practice Address - Fax:810-733-8424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI259103251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4708865Medicaid
MI5008704430OtherBLUE CROSS BLUE SHIELD
MA=========OtherTAX ID
MI4708865Medicaid
MAP09670001Medicare ID - Type UnspecifiedMEMBER #
MI0P09670Medicare ID - Type Unspecified