MEDICARE: HEROES PEDIATRIC HOSPICE AGENCY L.L.C

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	:	1770946345
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEROES PEDIATRIC HOSPICE AGENCY L.L.C

Provider Business Mailing Address
First Line	:	PO BOX 20651
Second Line	:
City	:	GREENVILLE
State	:	NC
Zip	:	27858-0651
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	110 WOODSIDE RD
Second Line	:
City	:	GREENVILLE
State	:	NC
Zip	:	27834-1129
Country	:	US
Telephone Number	:	919-295-6530
Fax Number	:

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	MRS. TANISHA JOHNSON
Credential	:
Telephone Number	:	919-295-6530

Provider Enumeration Date	:	03/31/2016
Last Update Date	:	03/31/2016

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