Healthcare Provider Details

I. General information

NPI: 1104548478
Provider Name (Legal Business Name): BRISTOL HOSPICE - CHICAGO, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2022
Last Update Date: 09/14/2022
Certification Date: 09/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 LEE ST STE 480
DES PLAINES IL
60016-4546
US

IV. Provider business mailing address

206 N 2100 W STE 202
SALT LAKE CITY UT
84116-4741
US

V. Phone/Fax

Practice location:
  • Phone: 872-777-1750
  • Fax: 872-702-6450
Mailing address:
  • Phone: 801-325-0175
  • Fax: 801-478-3533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. ALEX MAURICIO
Title or Position: PRESIDENT
Credential:
Phone: 801-325-0175