Healthcare Provider Details

I. General information

NPI: 1174579890
Provider Name (Legal Business Name): OPTUM PALLIATIVE AND HOSPICE CARE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 11/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3720 DA VINCI COURT SUITE 400
NORCROSS GA
30092
US

IV. Provider business mailing address

PO BOX 15645
LAS VEGAS NV
89114-5645
US

V. Phone/Fax

Practice location:
  • Phone: 770-417-2018
  • Fax: 888-652-6961
Mailing address:
  • Phone: 770-417-2018
  • Fax: 888-652-6961

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number067-243-H
License Number StateGA

VIII. Authorized Official

Name: JOHN O ENDERLE
Title or Position: PRESIDENT/CEO
Credential:
Phone: 860-221-0793