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General NPI Number Information
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NPI Number | 1467481101
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Entity Type | Organization
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Legal Business Name | ETERNITY HOSPICE INC.
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Dates
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Enumeration Date | 07/03/2006
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Last Update Date | 03/26/2009
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Provider Practice Location Address
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Address Line | 12000 MOBILE AVE
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City | GULFPORT
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State | MS
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Zip | 39503-3113
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Country | US
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Telephone | 228-832-7211
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Fax | 228-832-7213
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Provider Business Mailing Address
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Address Line | 12000 MOBILE AVE
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City | GULFPORT
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State | MS
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Zip | 39503-3113
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Country | US
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Telephone | 228-832-7211
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Fax | 228-832-7213
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Authorized Official
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Title or Position | PRESIDENT
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Name | CHARLES FAIRLEY
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Credential |
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Telephone | 601-517-0025
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251G00000X
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Taxonomy Name | Community Based Hospice Care Agency
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License Number | 251617
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License Number State | MS
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