Provider Demographics
NPI:1306152152
Name:GRACE HOSPICE OF ARIZONA, INC.
Entity type:Organization
Organization Name:GRACE HOSPICE OF ARIZONA, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SECRETARY / TREASURER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-894-3487
Mailing Address - Street 1:5314 S YALE AVE
Mailing Address - Street 2:SUITE 420
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-6256
Mailing Address - Country:US
Mailing Address - Phone:918-289-2553
Mailing Address - Fax:
Practice Address - Street 1:10631 PARAMOUNT BLVD
Practice Address - Street 2:
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90241-3303
Practice Address - Country:US
Practice Address - Phone:562-904-7000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-30
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ031587Medicare Oscar/Certification
CA551553Medicare Oscar/Certification