Provider Demographics
NPI:1366947152
Name:NORTHLAND HOSPICE & PALLIATIVE CARE INC
Entity type:Organization
Organization Name:NORTHLAND HOSPICE & PALLIATIVE CARE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:A
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-774-1227
Mailing Address - Street 1:220 W FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-1477
Mailing Address - Country:US
Mailing Address - Phone:928-779-1227
Mailing Address - Fax:
Practice Address - Street 1:452 N SWITZER CANYON DR
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-4855
Practice Address - Country:US
Practice Address - Phone:928-779-1227
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHLAND HOSPICE & PALLIATIVE CARE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-03-26
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL10516H177F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes177F00000XOther Service ProvidersLodging
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ110495Medicaid
AZ726185Medicaid