Charles WM. Leighton Jr Hospice, Inc.
Organization Active NPI Community Based Hospice Care Agency · Willcox, AZ
NPI 1366440083 · NPPES record last updated Dec 28, 2021
Key facts
- NPI
- 1366440083
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Community Based Hospice Care Agency 251G00000X
- License
- HSPC-2902 (AZ)
- Legal business name
- CHARLES WM. LEIGHTON JR HOSPICE, INC.
- Practice address
- 524 West Maley Place
Willcox, AZ 85643 - Phone
- (520) 384-5878
- Fax
- (520) 384-4127
- NPI assigned
- Jul 7, 2005
- Organization subpart
- No
Authorized official
- Name
- Mr. Gordon D Douglas
- Title
- Administrator
- Phone
- (520) 384-5878
Owners & managing parties with NPI records 1
-
Troy Lee Garey, DMD
Practitioners 1
-
Kerri Hendricks, RN
Affiliated clinicians 3
-
Trevor Alan Jones, FNP-C
-
Monica R Vandivort, M.D.
Medicare Care Compare: Hospice
- Listed as
- Charles WM. Leighton, Jr. Hospice, Inc.
- Ownership
- Other
- Certified
- Aug 2, 2001
- Medicare certification status
- Active
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 03D0987380 | Charles WM Leighton Jr Hospice | Certificate of waiver | Jun 3, 2027 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in AZ
Hospice certification: CCN 031551
- Legal name
- CHARLES WM LEIGHTON JR HOSPICE INC
- Certification status
- Active
- Provider type (POS)
- Hospice
- Participating since
- Aug 2, 2001
- Last certification
- Feb 26, 2021
- Ownership / control type
- Proprietary - Individual
- Organization structure
- Corporation · Non-profit
- Incorporated
- Nov 13, 1996 in AZ
- Enrollment address
- 524W Maley PL
Willcox, AZ 85643-2042
All disclosed owners & managing parties 6
| Name | Role | Since | Share |
|---|---|---|---|
| Mary Leighton |
Corporate Director | Oct 30, 2007 | |
| Gordon (Dan) Douglas |
Corporate Director |
May 29, 2001 | |
| Troy Lee Garey |
Corporate Director | Oct 31, 2006 | |
| Kerri Armstrong |
W-2 Managing Employee | May 20, 2017 | |
| Diane Truschke |
Corporate Director | Mar 29, 2007 | |
| Thomas L Riggs |
Corporate Director |
Oct 25, 2013 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20050915000466 | AZ | Part a Provider - Hospice | 1850324286 | Practice locations: Willcox, AZ |
National Provider Directory
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Community Based Hospice Care Agency | 251G00000X | HSPC-2902 | AZ | Yes |
Addresses
Primary practice location
524 West Maley Place
Willcox, AZ 85643
Mailing address
P.O. Box 115
Willcox, AZ 85644
Phone (520) 384-5878
Other names
- Charles Wm. Leighton Hospice, Inc.
Other providers in Willcox, AZ
- Amanda Dawn Bennett
- Dale Todd Bennett
- Nickalaus David Bryce
- Jeffery Burl Bushman
- Abby F Camisa
- Child & Family Resources, Inc.
- Chiricahua Community Health Centers, Inc.
- Amanda Ann Davis
- Sunny Lynn De Baun
- Angela Diaz
All providers in Willcox, AZ · Community Based Hospice Care Agency in Arizona
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Dec 28, 2021. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.