Basic Information
| Provider Information | |||||||||
| NPI: | 1265607519 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FMC HOSPICE - CONROE LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | EMBRACING HOSPICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 50 N LAURA ST STE 1800 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322023614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9044936745 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2040 NORTH LOOP 336 WEST | ||||||||
| Address2: | SUITE 324 | ||||||||
| City: | CONROE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773043592 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9367885900 | ||||||||
| FaxNumber: | 9367885902 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2008 | ||||||||
| LastUpdateDate: | 05/17/2012 | ||||||||
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| AuthorizedOfficialLastName: | FOGLE | ||||||||
| AuthorizedOfficialFirstName: | RICH | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9044936748 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | Y | Agencies | Hospice Care, Community Based |
ID Information
| ID | Type | State | Issuer | Description | 012053 | 01 | TX | STATE LICENSE | OTHER | 001017834 | 05 | TX | MEDICAID |