MEDICARE: SACRED ONE HOSPICE, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251G00000X	Community Based Hospice Care Agency	550000246	CA

General Provider Information

NPI Number	:	1073859237
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SACRED ONE HOSPICE, INC.

Provider Business Mailing Address
First Line	:	3699 WILSHIRE BLVD
Second Line	:	SUITE 870
City	:	LOS ANGELES
State	:	CA
Zip	:	90010-2718
Country	:	US
Telephone Number	:	213-368-0254
Fax Number	:	213-368-0258

Provider Business Practice Location Address
First Line	:	3699 WILSHIRE BLVD
Second Line	:	SUITE 870
City	:	LOS ANGELES
State	:	CA
Zip	:	90010-2718
Country	:	US
Telephone Number	:	213-368-0254
Fax Number	:	213-368-0258

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. MAX LOPEZ
Credential	:	REGISTERED NURSE
Telephone Number	:	562-841-0714

Provider Enumeration Date	:	12/17/2012
Last Update Date	:	02/25/2013

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