MEDICARE: CROSS TIMBERS 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	4056	OK

General Provider Information

NPI Number	:	1669475513
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CROSS TIMBERS HOSPICE, INC

Provider Business Mailing Address
First Line	:	207 C ST NW
Second Line	:
City	:	ARDMORE
State	:	OK
Zip	:	73401-6216
Country	:	US
Telephone Number	:	580-223-0655
Fax Number	:	580-223-3267

Provider Business Practice Location Address
First Line	:	207 C ST NW
Second Line	:
City	:	ARDMORE
State	:	OK
Zip	:	73401-6216
Country	:	US
Telephone Number	:	580-223-0655
Fax Number	:	580-223-3267

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. MARK A DODGE
Credential	:	C.P.A.
Telephone Number	:	580-223-0655

Provider Enumeration Date	:	05/24/2005
Last Update Date	:	10/22/2010

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