Provider Demographics
NPI:1710252713
Name:GRACE HOSPICE OF EAST TEXAS, LLC.
Entity Type:Organization
Organization Name:GRACE HOSPICE OF EAST TEXAS, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:KIRK
Authorized Official - Middle Name:B
Authorized Official - Last Name:WIED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-747-3990
Mailing Address - Street 1:4100 INTERNATIONAL PLZ
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-4820
Mailing Address - Country:US
Mailing Address - Phone:903-747-3990
Mailing Address - Fax:817-735-4323
Practice Address - Street 1:3324 S KEATON AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-9055
Practice Address - Country:US
Practice Address - Phone:903-747-3990
Practice Address - Fax:817-735-4323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-09
Last Update Date:2017-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based