Basic Information
| Provider Information | |||||||||
| NPI: | 1093004178 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HARBOR HOSPICE OF HOUSTON, LP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3406 COLLEGE ST # 200 | ||||||||
| Address2: | |||||||||
| City: | BEAUMONT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 777014612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4098132332 | ||||||||
| FaxNumber: | 4092320573 | ||||||||
| Practice Location | |||||||||
| Address1: | 1322 SPACE PARK DR STE A194 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770583464 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2814616109 | ||||||||
| FaxNumber: | 2814616038 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2011 | ||||||||
| LastUpdateDate: | 01/29/2016 | ||||||||
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| AuthorizedOfficialLastName: | THIBODAUX | ||||||||
| AuthorizedOfficialFirstName: | BRAD | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF DATA OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4098132332 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | 14077 | TX | Y | Agencies | Hospice Care, Community Based |
ID Information
| ID | Type | State | Issuer | Description | 14077 | 01 | TX | TDADS LICENSE | OTHER | 01026079 | 05 | TX | MEDICAID | 67-1745 | 01 | MEDICARE CCN | OTHER | 45D2027431 | 01 | CLIA | OTHER |