Provider Demographics
NPI:1225382518
Name:AMIGOS CRISTIANOS LLC
Entity Type:Organization
Organization Name:AMIGOS CRISTIANOS LLC
Other - Org Name:TEXAS STATE HEALTHCARE & HOSPICE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:S
Authorized Official - Last Name:FODRIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:979-323-7099
Mailing Address - Street 1:1700 6TH STREET
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77414-5021
Mailing Address - Country:US
Mailing Address - Phone:979-323-7099
Mailing Address - Fax:979-323-0555
Practice Address - Street 1:1700 6TH STREET
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:TX
Practice Address - Zip Code:77414-5021
Practice Address - Country:US
Practice Address - Phone:979-323-7099
Practice Address - Fax:979-323-0555
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AMIGOS CRISTIANOS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-11-08
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX015661251G00000X, 251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX671782Medicare PIN