Provider Demographics
NPI:1093783854
Name:SPIRIT HEALTHCARE MANAGEMENT, LLC
Entity Type:Organization
Organization Name:SPIRIT HEALTHCARE MANAGEMENT, LLC
Other - Org Name:SPIRIT HOMECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:SHELLY
Authorized Official - Last Name:OTTO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-296-5959
Mailing Address - Street 1:1636 N HAMPTON RD
Mailing Address - Street 2:108
Mailing Address - City:DESOTO
Mailing Address - State:TX
Mailing Address - Zip Code:75115-8621
Mailing Address - Country:US
Mailing Address - Phone:972-296-5959
Mailing Address - Fax:972-709-5152
Practice Address - Street 1:1636 N HAMPTON RD
Practice Address - Street 2:108
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-8621
Practice Address - Country:US
Practice Address - Phone:972-296-5959
Practice Address - Fax:972-709-5152
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-09
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX003436251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX458371Medicare ID - Type UnspecifiedPROVIDER NUMBER