Provider Demographics
NPI:1962407700
Name:CRATER COMMUNITY HOSPICE INC
Entity type:Organization
Organization Name:CRATER COMMUNITY HOSPICE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:D
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:RN, MSN, CS, CHPN
Authorized Official - Phone:804-526-4300
Mailing Address - Street 1:3916 S CRATER RD
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23805-9202
Mailing Address - Country:US
Mailing Address - Phone:804-526-4300
Mailing Address - Fax:804-526-4337
Practice Address - Street 1:3916 S CRATER RD
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23805-9202
Practice Address - Country:US
Practice Address - Phone:804-526-4300
Practice Address - Fax:804-526-4924
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-17
Last Update Date:2010-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0515-15251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
337221OtherBLUE CROSS PROVIDER ID
VA004910192Medicaid
VA004910192Medicaid
=========OtherTRICARE PROVIDER ID
=========OtherAETNA INS PROVIDER ID