Basic Information
| Provider Information | |||||||||
| NPI: | 1558772905 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MY OWN HOSPICE LLC | ||||||||
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| OtherOrganizationName: | OPUSCARE OF TEXAS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6900 SW 80TH ST | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331434931 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3055911606 | ||||||||
| FaxNumber: | 3055911618 | ||||||||
| Practice Location | |||||||||
| Address1: | 2943 MOSSROCK | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782305119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2109881461 | ||||||||
| FaxNumber: | 2104049887 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2014 | ||||||||
| LastUpdateDate: | 12/15/2020 | ||||||||
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| AuthorizedOfficialLastName: | ROQUE-VELASCO | ||||||||
| AuthorizedOfficialFirstName: | ISMAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 3055911606 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0002X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hospice and Palliative Medicine | 251G00000X | 018026 | TX | Y | Agencies | Hospice Care, Community Based |
ID Information
| ID | Type | State | Issuer | Description | 741589 | 01 | TX | MEDICARE CCN | OTHER |