1265607519 NPI number — FMC HOSPICE - CONROE LLC

Table of content: (NPI 1265607519)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265607519 NPI number — FMC HOSPICE - CONROE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FMC HOSPICE - CONROE LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
EMBRACING HOSPICE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265607519
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/17/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
50 N LAURA ST STE 1800
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32202-3614
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-493-6745
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2040 NORTH LOOP 336 WEST
Provider Second Line Business Practice Location Address:
SUITE 324
Provider Business Practice Location Address City Name:
CONROE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77304-3592
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
936-788-5900
Provider Business Practice Location Address Fax Number:
936-788-5902
Provider Enumeration Date:
04/28/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
FOGLE
Authorized Official First Name:
RICH
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
904-493-6748

Provider Taxonomy Codes

  • Taxonomy code: 251G00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 012053 . This is a "STATE LICENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 001017834 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".