=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700564937
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LILY HOME AND HOSPICE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/07/2023
-----------------------------------------------------
Last Update Date | 12/11/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4423 GOLF TER STE A
-----------------------------------------------------
City | EAU CLAIRE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54701-4902
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-421-6004
-----------------------------------------------------
Fax | 262-537-5140
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15430 W CAPITOL DR STE 100
-----------------------------------------------------
City | BROOKFIELD
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53005-2626
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-235-3115
-----------------------------------------------------
Fax | 262-537-5140
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | KEITH RASIMUS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 715-201-2233
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251G00000X
-----------------------------------------------------
Taxonomy Name | Community Based Hospice Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------