MEDICARE: CHARLES WM. LEIGHTON JR 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	HSPC-2902	AZ

General Provider Information

NPI Number	:	1366440083
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHARLES WM. LEIGHTON JR HOSPICE, INC.

Provider Business Mailing Address
First Line	:	P.O. BOX 115
Second Line	:
City	:	WILLCOX
State	:	AZ
Zip	:	85644
Country	:	US
Telephone Number	:	520-384-5878
Fax Number	:	520-384-4127

Provider Business Practice Location Address
First Line	:	524 WEST MALEY PLACE
Second Line	:
City	:	WILLCOX
State	:	AZ
Zip	:	85643
Country	:	US
Telephone Number	:	520-384-5878
Fax Number	:	520-384-4127

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. GORDON D DOUGLAS
Credential	:
Telephone Number	:	520-384-5878

Provider Enumeration Date	:	07/07/2005
Last Update Date	:	12/28/2021

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