Provider Demographics
NPI:1437374493
Name:BLUEBONNET HOSPICE OF EAST TEXAS, INC.
Entity Type:Organization
Organization Name:BLUEBONNET HOSPICE OF EAST TEXAS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO CFO
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:FETTINGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-275-1040
Mailing Address - Street 1:3607 W PIONEER PKWY
Mailing Address - Street 2:
Mailing Address - City:PANTEGO
Mailing Address - State:TX
Mailing Address - Zip Code:76013-4504
Mailing Address - Country:US
Mailing Address - Phone:817-275-1040
Mailing Address - Fax:
Practice Address - Street 1:7524 S BROADWAY AVE STE 113
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-5000
Practice Address - Country:US
Practice Address - Phone:903-561-7751
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX010273374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX671554Medicare ID - Type UnspecifiedPROVIDER NUMBER