Provider Demographics
NPI:1023089257
Name:PREMIER HOSPICE, INC.
Entity type:Organization
Organization Name:PREMIER HOSPICE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:HUDDLESTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-756-7640
Mailing Address - Street 1:PO BOX 610
Mailing Address - Street 2:
Mailing Address - City:DEMOTTE
Mailing Address - State:IN
Mailing Address - Zip Code:46310-0610
Mailing Address - Country:US
Mailing Address - Phone:219-756-7640
Mailing Address - Fax:219-756-3876
Practice Address - Street 1:1600 167TH ST
Practice Address - Street 2:SUITE 33
Practice Address - City:CALUMET CITY
Practice Address - State:IL
Practice Address - Zip Code:60409-5457
Practice Address - Country:US
Practice Address - Phone:219-756-7640
Practice Address - Fax:219-756-3876
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2001865251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========001Medicaid