Basic Information
| Provider Information | |||||||||
| NPI: | 1962799528 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HARBOR HOSPICE OF LIBERTY LP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3406 COLLEGE ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | BEAUMONT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 777014612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4098132332 | ||||||||
| FaxNumber: | 4098387598 | ||||||||
| Practice Location | |||||||||
| Address1: | 623 MAIN ST STE 2 | ||||||||
| Address2: | |||||||||
| City: | LIBERTY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775754848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9366419431 | ||||||||
| FaxNumber: | 9366419187 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2011 | ||||||||
| LastUpdateDate: | 11/23/2020 | ||||||||
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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: | 11/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | Y | Agencies | Hospice Care, Community Based |
ID Information
| ID | Type | State | Issuer | Description | 67-1735 | 01 | MEDICARE PTAN | OTHER | 014311 | 01 | TX | TXDADS | OTHER | 45D2034839 | 01 | TX | CLIA | OTHER |