Healthcare Provider Details

I. General information

NPI: 1750009452
Provider Name (Legal Business Name): RESIDENTIAL HOSPICE OF SOUTHERN ILLINOIS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2022
Last Update Date: 08/18/2022
Certification Date: 08/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8706 MANCHESTER RD STE 102
SAINT LOUIS MO
63144-2733
US

IV. Provider business mailing address

5440 CORPORATE DR STE 400
TROY MI
48098-2645
US

V. Phone/Fax

Practice location:
  • Phone: 314-266-0950
  • Fax:
Mailing address:
  • Phone: 866-902-4000
  • Fax: 866-903-4000

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: JUSTIN DEWITTE
Title or Position: PRESIDENT / CEO
Credential:
Phone: 866-902-4000