Basic Information
| Provider Information | |||||||||
| NPI: | 1316029770 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EAST TEXAS MEDICAL CENTER HOME SERVICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | EAST TEXAS MEDICAL CENTER HOME HEALTH - NORTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19 COUNTY ROAD 4114 | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | PITTSBURG | ||||||||
| State: | TX | ||||||||
| PostalCode: | 756864199 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9038566554 | ||||||||
| FaxNumber: | 9038560084 | ||||||||
| Practice Location | |||||||||
| Address1: | 19 COUNTY ROAD 4114 | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | PITTSBURG | ||||||||
| State: | TX | ||||||||
| PostalCode: | 756864199 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9038566554 | ||||||||
| FaxNumber: | 9038560084 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2006 | ||||||||
| LastUpdateDate: | 01/30/2017 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | CURT | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CORP. DIRECTOR/ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9035356056 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 010659 | TX | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 1383747-02 | 05 | TX | MEDICAID |