MEDICARE: BRISTOL HOSPICE - GEORGIA 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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1558663872
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRISTOL HOSPICE - GEORGIA LLC

Provider Business Mailing Address
First Line	:	206 N 2100 W STE 202
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84116-4741
Country	:	US
Telephone Number	:	801-325-0175
Fax Number	:

Provider Business Practice Location Address
First Line	:	2849 PACES FERRY RD SE STE 380
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30339-3769
Country	:	US
Telephone Number	:	770-434-9530
Fax Number	:	770-434-9529

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	ALEX MAURICIO
Credential	:
Telephone Number	:	801-325-0175

Provider Enumeration Date	:	11/18/2010
Last Update Date	:	09/26/2023

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