Healthcare Provider Details

I. General information

NPI: 1184887572
Provider Name (Legal Business Name): HOSPICE PEACHTREE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2008
Last Update Date: 07/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 N BROADWAY ST
POTEAU OK
74953-5428
US

IV. Provider business mailing address

PO BOX 460
POTEAU OK
74953-0460
US

V. Phone/Fax

Practice location:
  • Phone: 918-647-7008
  • Fax: 918-647-7168
Mailing address:
  • Phone: 918-647-7008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number4057
License Number StateOK

VIII. Authorized Official

Name: JIM PETRUS
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 479-494-0100