Provider Demographics
NPI:1215084876
Name:SAFE HARBOR HOSPICE, LLC
Entity type:Organization
Organization Name:SAFE HARBOR HOSPICE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:LEWIS
Authorized Official - Middle Name:C
Authorized Official - Last Name:BLAIR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:052-742-0028
Mailing Address - Street 1:PO BOX 2130
Mailing Address - Street 2:
Mailing Address - City:DAPHNE
Mailing Address - State:AL
Mailing Address - Zip Code:36526-2130
Mailing Address - Country:US
Mailing Address - Phone:205-652-6167
Mailing Address - Fax:205-742-0028
Practice Address - Street 1:101 KINGSBURY BLVD
Practice Address - Street 2:
Practice Address - City:FREDERICKTOWN
Practice Address - State:MO
Practice Address - Zip Code:63645-7959
Practice Address - Country:US
Practice Address - Phone:573-783-7625
Practice Address - Fax:573-783-2126
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1076HO251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO825025000Medicaid