Basic Information
Provider Information | |||||||||
NPI: | 1013901719 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ANGEL HEART HOSPICE, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | NEW CENTURY HOSPICE OF AUSTIN | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | P.O. BOX 4060 ATTN: REGULATORY | ||||||||
Address2: |   | ||||||||
City: | MOORESVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 281174060 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7046642876 | ||||||||
FaxNumber: | 7046641306 | ||||||||
Practice Location | |||||||||
Address1: | 9430 RESEARCH BLVD | ||||||||
Address2: | BLDG. II, #100 | ||||||||
City: | AUSTIN | ||||||||
State: | TX | ||||||||
PostalCode: | 787596586 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5123428288 | ||||||||
FaxNumber: | 5123428122 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/08/2005 | ||||||||
LastUpdateDate: | 10/11/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | COMBS | ||||||||
AuthorizedOfficialFirstName: | JANET | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VP LICENSURE | ||||||||
AuthorizedOfficialTelephone: | 9138142013 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/11/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X |   |   | Y |   | Agencies | Hospice Care, Community Based |   |
ID Information
ID | Type | State | Issuer | Description | 001013622 | 05 | TX |   | MEDICAID | 0010299121 | 05 | TX |   | MEDICAID | 001029921 | 05 | TX |   | MEDICAID |