MEDICARE: AVALON HOSPICE MISSOURI, LLC

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

General Provider Information

NPI Number	:	1174060529
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AVALON HOSPICE MISSOURI, LLC

Provider Business Mailing Address
First Line	:	655 BRAWLEY SCHOOL RD
Second Line	:	SUITE 200
City	:	MOORESVILLE
State	:	NC
Zip	:	28117-9125
Country	:	US
Telephone Number	:	704-664-2876
Fax Number	:	704-664-1306

Provider Business Practice Location Address
First Line	:	5615 PERSHING AVE
Second Line	:	SUITE 20
City	:	SAINT LOUIS
State	:	MO
Zip	:	63112-1757
Country	:	US
Telephone Number	:	314-328-6700
Fax Number	:	314-546-4400

Authorized Official
Title or Position	:	VP LEGAL AFFAIRS
Name	:	JESSICA KLEBERG
Credential	:
Telephone Number	:	704-664-2876

Provider Enumeration Date	:	01/24/2017
Last Update Date	:	03/09/2017

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