MEDICARE: MEDISTAR HOSPICE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WH1000X	Hospice Registered Nurse

General Provider Information

NPI Number	:	1982217337
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDISTAR HOSPICE

Provider Business Mailing Address
First Line	:	17547 VENTURA BLVD STE 205
Second Line	:
City	:	ENCINO
State	:	CA
Zip	:	91316-3854
Country	:	US
Telephone Number	:	818-635-3501
Fax Number	:

Provider Business Practice Location Address
First Line	:	17547 VENTURA BLVD STE 205
Second Line	:
City	:	ENCINO
State	:	CA
Zip	:	91316-3854
Country	:	US
Telephone Number	:	818-635-3501
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	INNA ZHIVILOVA
Credential	:
Telephone Number	:	818-635-3501

Provider Enumeration Date	:	08/26/2020
Last Update Date	:	08/26/2020

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