MEDICARE: CRATER COMMUNITY 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	0515-15	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	337221	OTHER		BLUE CROSS PROVIDER ID
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1962407700
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CRATER COMMUNITY HOSPICE INC

Provider Business Mailing Address
First Line	:	3916 S CRATER RD
Second Line	:
City	:	PETERSBURG
State	:	VA
Zip	:	23805-9202
Country	:	US
Telephone Number	:	804-526-4300
Fax Number	:	804-526-4337

Provider Business Practice Location Address
First Line	:	3916 S CRATER RD
Second Line	:
City	:	PETERSBURG
State	:	VA
Zip	:	23805-9202
Country	:	US
Telephone Number	:	804-526-4300
Fax Number	:	804-526-4924

Authorized Official
Title or Position	:	CEO
Name	:	MRS. BRENDA D. MITCHELL
Credential	:	RN, MSN, CS, CHPN
Telephone Number	:	804-526-4300

Provider Enumeration Date	:	06/17/2005
Last Update Date	:	06/09/2010

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Directions to “CRATER COMMUNITY HOSPICE INC ” Practice Location

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