Basic Information
| Provider Information | |||||||||
| NPI: | 1912932948 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HOSPICE OF THE PALM COAST INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ODYSSEY HEALTHCARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 717 N HARWOOD ST | ||||||||
| Address2: | SUITE 1500 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752016519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2149229711 | ||||||||
| FaxNumber: | 2149229752 | ||||||||
| Practice Location | |||||||||
| Address1: | 6161 BLUE LAGOON DRIVE | ||||||||
| Address2: | SUITE 170 | ||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331262045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7863881400 | ||||||||
| FaxNumber: | 7863881401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 08/25/2009 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ALLISON | ||||||||
| AuthorizedOfficialFirstName: | RODNEY | ||||||||
| AuthorizedOfficialMiddleName: | DIRK | ||||||||
| AuthorizedOfficialTitleorPosition: | SR VP & CFO | ||||||||
| AuthorizedOfficialTelephone: | 2149229711 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | 50370970 | FL | Y | Agencies | Hospice Care, Community Based |
ID Information
| ID | Type | State | Issuer | Description | 150019800 | 05 | FL | MEDICAID |