Healthcare Provider Details

I. General information

NPI: 1245268853
Provider Name (Legal Business Name): FAMILY HOSPICE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 03/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1790 30TH ST STE 308
BOULDER CO
80301-1020
US

IV. Provider business mailing address

655 BRAWLEY SCHOOL RD SUITE 200
MOORESVILLE NC
28117-9601
US

V. Phone/Fax

Practice location:
  • Phone: 303-440-0205
  • Fax: 303-440-0209
Mailing address:
  • Phone: 704-664-2876
  • Fax: 704-664-1306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number0784
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number17B941
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier89986741
Identifier TypeMEDICAID
Identifier StateCO
Identifier Issuer

VIII. Authorized Official

Name: JESSICA L. KIEBERG
Title or Position: VP OF LEGAL AFFAIRS
Credential:
Phone: 704-662-0414