Healthcare Provider Details

I. General information

NPI: 1023267218
Provider Name (Legal Business Name): HOSPICE PEACHTREE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2008
Last Update Date: 03/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2910 JENNY LIND RD #4
FORT SMITH AR
72901-6735
US

IV. Provider business mailing address

2910 JENNY LIND RD #4
FORT SMITH AR
72901-6735
US

V. Phone/Fax

Practice location:
  • Phone: 479-494-0100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License NumberAR 4137
License Number StateAR

VIII. Authorized Official

Name: JIM PETRUS
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 479-494-0100