Provider Demographics
NPI:1043683170
Name:BRISTOL HOSPICE - INLAND EMPIRE, LLC
Entity type:Organization
Organization Name:BRISTOL HOSPICE - INLAND EMPIRE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ALEX
Authorized Official - Middle Name:
Authorized Official - Last Name:MAURICIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-325-0175
Mailing Address - Street 1:206 N 2100 W STE 202
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84116-4741
Mailing Address - Country:US
Mailing Address - Phone:801-325-0175
Mailing Address - Fax:
Practice Address - Street 1:6296 RIVER CREST DR STE L
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-0738
Practice Address - Country:US
Practice Address - Phone:951-308-6000
Practice Address - Fax:951-308-6009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-11
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3820480251G00000X, 251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1043683170Medicaid