=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386983112
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAN PEDRO HOSPICE INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/14/2013
-----------------------------------------------------
Last Update Date | 02/21/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 605 S PACIFIC AVE STE 200
-----------------------------------------------------
City | SAN PEDRO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90731-2664
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-731-6083
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 605 S PACIFIC AVE STE 200
-----------------------------------------------------
City | SAN PEDRO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90731-2664
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-731-6083
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MARY KODJOGLIAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 818-731-6083
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251G00000X
-----------------------------------------------------
Taxonomy Name | Community Based Hospice Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------