Basic Information
| Provider Information | |||||||||
| NPI: | 1871632513 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHEAST TEXAS HOME HEALTH AGENCY LTD | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | AT HOME HEALTHCARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9846 STATE HIGHWAY 31 E | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757052329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035928001 | ||||||||
| FaxNumber: | 9035816918 | ||||||||
| Practice Location | |||||||||
| Address1: | 507 S MARSHALL ST | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 756543980 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9036571004 | ||||||||
| FaxNumber: | 9036572260 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2007 | ||||||||
| LastUpdateDate: | 06/18/2021 | ||||||||
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| AuthorizedOfficialLastName: | SIEGENTHALER | ||||||||
| AuthorizedOfficialFirstName: | LARA | ||||||||
| AuthorizedOfficialMiddleName: | DIANNE | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9035253912 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 002875 | TX | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 023843801 | 05 | TX | MEDICAID | HH8314 | 01 | TX | BLUECROSS BLUE SHIELD | OTHER |