- Enrollment id
- O20120425000311
- Enrollment state
- OK
- Provider type code
- 00-08
- Provider type text
- PART A PROVIDER - HOSPICE
- Npi
- 1740339548
- Multiple npi flag
- N
- Ccn
- 371644
- Associate id
- 9830178086
- Organization name
- EVERGREEN HOSPICE LLC
- Doing business as name
- LUMINOS HOSPICE
- Organization type structure
- LLC
- Proprietary nonprofit
- P
- Address line 1
- 4110 S ROCKFORD AVE
- Address line 2
- STE 201
- City
- TULSA
- State
- OK
- Zip code
- 741054251