Healthcare Provider Details

I. General information

NPI: 1114627890
Provider Name (Legal Business Name): ODYSSEY HEALTHCARE HOLDING COMPANY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2023
Last Update Date: 03/09/2023
Certification Date: 03/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

695 KENMOOR AVE SE STE B
GRAND RAPIDS MI
49546-2375
US

IV. Provider business mailing address

PO BOX 4060
MOORESVILLE NC
28117-4060
US

V. Phone/Fax

Practice location:
  • Phone: 616-956-0636
  • Fax:
Mailing address:
  • Phone: 704-664-2876
  • Fax:

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: JANET COMBS
Title or Position: VP OF LICENSURE
Credential:
Phone: 704-664-2876