=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649537150
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROMISE HOSPICE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/20/2012
-----------------------------------------------------
Last Update Date | 04/30/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2140 W. OLYMPIC BLVD SUITE 326
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90006-2279
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-205-2587
-----------------------------------------------------
Fax | 310-362-8805
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2140 W. OLYMPIC BLVD SUITE 326
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90006-2279
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-205-2587
-----------------------------------------------------
Fax | 310-362-8805
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | ZULFICAR GREGORY RESTUM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 310-205-2587
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251G00000X
-----------------------------------------------------
Taxonomy Name | Community Based Hospice Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------