1013901719 NPI number — ANGEL HEART HOSPICE, LLC

Table of content: (NPI 1013901719)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013901719 NPI number — ANGEL HEART HOSPICE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ANGEL HEART HOSPICE, 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:
Provider Other Organization Name Type Code:
6
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:
1013901719
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/11/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 4060 ATTN: REGULATORY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOORESVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28117-4060
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-664-2876
Provider Business Mailing Address Fax Number:
704-664-1306

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9430 RESEARCH BLVD
Provider Second Line Business Practice Location Address:
BLDG. II, #100
Provider Business Practice Location Address City Name:
AUSTIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78759-6586
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-342-8288
Provider Business Practice Location Address Fax Number:
512-342-8122
Provider Enumeration Date:
09/08/2005

Additional Information

Authorized Official

Authorized Official Last Name:
COMBS
Authorized Official First Name:
JANET
Authorized Official Middle Name:
Authorized Official Title or Position:
VP LICENSURE
Authorized Official Telephone Number:
704-664-2876

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: 0010299121 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 001013622 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 001029921 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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