Provider Demographics
NPI:1710986807
Name:EAST TEXAS MEDICAL CENTER HOME SERVICES
Entity Type:Organization
Organization Name:EAST TEXAS MEDICAL CENTER HOME SERVICES
Other - Org Name:ETMC HOME HEALTH - SOUTH, HOSPICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AREA DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MS
Authorized Official - First Name:TRACI
Authorized Official - Middle Name:K
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-535-6056
Mailing Address - Street 1:734 W COMMERCE ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:75840-1406
Mailing Address - Country:US
Mailing Address - Phone:903-389-3504
Mailing Address - Fax:903-389-3541
Practice Address - Street 1:734 W COMMERCE ST
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:TX
Practice Address - Zip Code:75840-1406
Practice Address - Country:US
Practice Address - Phone:903-389-3504
Practice Address - Fax:903-389-3541
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX007375251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX45-1746Medicare ID - Type UnspecifiedHOSPICE PROVIDER