Provider Demographics
NPI:1184887572
Name:HOSPICE PEACHTREE, LLC
Entity type:Organization
Organization Name:HOSPICE PEACHTREE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:PETRUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-494-0100
Mailing Address - Street 1:PO BOX 460
Mailing Address - Street 2:
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953-0460
Mailing Address - Country:US
Mailing Address - Phone:918-647-7008
Mailing Address - Fax:
Practice Address - Street 1:3100 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953-5428
Practice Address - Country:US
Practice Address - Phone:918-647-7008
Practice Address - Fax:918-647-7168
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-07
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4057251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100679750 BMedicaid
OK371554Medicare Oscar/Certification