Basic Information
| Provider Information | |||||||||
| NPI: | 1508116963 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HARBOR HOSPICE OF SOUTHEAST HOUSTON, LP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3406 COLLEGE ST # 200 | ||||||||
| Address2: | ATTN: LICENSING & CREDENTIALING | ||||||||
| City: | BEAUMONT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 777014612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4098132332 | ||||||||
| FaxNumber: | 4092320573 | ||||||||
| Practice Location | |||||||||
| Address1: | 11990 KIRBY DR | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770454860 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7134135200 | ||||||||
| FaxNumber: | 7134135299 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2012 | ||||||||
| LastUpdateDate: | 04/20/2020 | ||||||||
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| AuthorizedOfficialLastName: | CARTER | ||||||||
| AuthorizedOfficialFirstName: | KAREN | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXEC ADMIN ASSISTANT | ||||||||
| AuthorizedOfficialTelephone: | 4097302046 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | N | Agencies | Hospice Care, Community Based | 315D00000X | 015201 | TX | Y | Nursing & Custodial Care Facilities | Hospice, Inpatient |
ID Information
| ID | Type | State | Issuer | Description | 45D2051000 | 01 | TX | CLIA ID | OTHER | 015201 | 01 | TX | STATE HOSPICE LICENSE | OTHER | 67-1774 | 01 | MEDICARE PTAN | OTHER |