Provider Demographics
NPI:1578931135
Name:CLASSIC HOSPICE LLC
Entity Type:Organization
Organization Name:CLASSIC HOSPICE LLC
Other - Org Name:CLASSIC HOSPICE & SENIOR CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:STACY
Authorized Official - Middle Name:L
Authorized Official - Last Name:HULSEY-BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:817-792-2030
Mailing Address - Street 1:4025 WOODLAND PARK BLVD STE 120
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76013-4301
Mailing Address - Country:US
Mailing Address - Phone:817-792-2030
Mailing Address - Fax:817-792-2031
Practice Address - Street 1:4025 WOODLAND PARK BLVD STE 120
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76013-4301
Practice Address - Country:US
Practice Address - Phone:817-792-2030
Practice Address - Fax:817-792-2031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-11
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXHHS000004700156Medicaid
TX45D2127221OtherCLIA