Healthcare Provider Details

I. General information

NPI: 1124065156
Provider Name (Legal Business Name): ETERNITY HOSPICE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2006
Last Update Date: 11/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

337 ELLISVILLE BLVD
LAUREL MS
39440-4523
US

IV. Provider business mailing address

337 ELLISVILLE BLVD
LAUREL MS
39440-4523
US

V. Phone/Fax

Practice location:
  • Phone: 601-649-4105
  • Fax: 601-649-4045
Mailing address:
  • Phone: 601-649-4105
  • Fax: 601-649-4045

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number127
License Number StateMS

VIII. Authorized Official

Name: MR. DONALD PUGH SR.
Title or Position: VICE PRESIDENT
Credential:
Phone: 601-517-0025