Provider Demographics
NPI:1144228859
Name:CHARTER HEALTHCARE OF DALLAS, LLC
Entity Type:Organization
Organization Name:CHARTER HEALTHCARE OF DALLAS, LLC
Other - Org Name:GENESIS HOSPICECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ATTORNEY
Authorized Official - Prefix:
Authorized Official - First Name:SYLVIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOAL
Authorized Official - Suffix:
Authorized Official - Credentials:ESQ
Authorized Official - Phone:909-644-4965
Mailing Address - Street 1:1317 S PALESTINE ST
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:TX
Mailing Address - Zip Code:75751-3600
Mailing Address - Country:US
Mailing Address - Phone:903-675-4730
Mailing Address - Fax:903-904-5003
Practice Address - Street 1:1317 S PALESTINE ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:TX
Practice Address - Zip Code:75751-3600
Practice Address - Country:US
Practice Address - Phone:903-675-4730
Practice Address - Fax:903-904-5003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX004415251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX000215000Medicaid
45-1657Medicare ID - Type Unspecified