1720300452 NPI number — COSMOS HOSPICE OF BEAUMONT, LLC

Table of content: (NPI 1720300452)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720300452 NPI number — COSMOS HOSPICE OF BEAUMONT, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COSMOS HOSPICE OF BEAUMONT, 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:
1720300452
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/01/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
655 BRAWLEY SCHOOL RD
Provider Second Line Business Mailing Address:
STE 200
Provider Business Mailing Address City Name:
MOORESVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28117-9125
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:
3965 PHELAN BLVD
Provider Second Line Business Practice Location Address:
SUITE 108
Provider Business Practice Location Address City Name:
BEAUMONT
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77707-2231
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
409-832-6700
Provider Business Practice Location Address Fax Number:
409-832-6703
Provider Enumeration Date:
02/22/2010

Additional Information

Authorized Official

Authorized Official Last Name:
KLEBERG
Authorized Official First Name:
JESSICA
Authorized Official Middle Name:
Authorized Official Title or Position:
VP OF LEGAL AFFAIRS
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: 013873 . This is a "STATE LICENSE" identifier . This identifiers is of the category "OTHER".




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