Provider Demographics
NPI:1073829479
Name:TRICARE HOSPICE, LLC
Entity Type:Organization
Organization Name:TRICARE HOSPICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BRANDI
Authorized Official - Middle Name:
Authorized Official - Last Name:TRAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-358-8000
Mailing Address - Street 1:25673 HIGHWAY 105 W
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TX
Mailing Address - Zip Code:77328-2973
Mailing Address - Country:US
Mailing Address - Phone:281-358-8000
Mailing Address - Fax:281-358-7999
Practice Address - Street 1:25673 HIGHWAY 105 W
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TX
Practice Address - Zip Code:77328-2973
Practice Address - Country:US
Practice Address - Phone:281-358-8000
Practice Address - Fax:281-358-7999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-23
Last Update Date:2018-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251G00000X
TX251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0010225833Medicaid
TX0010225833Medicaid