Provider Demographics
NPI:1730292848
Name:PROMISECARE HOSPICE INC
Entity Type:Organization
Organization Name:PROMISECARE HOSPICE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SAM
Authorized Official - Middle Name:
Authorized Official - Last Name:GHOSN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-248-1405
Mailing Address - Street 1:6302 SW LEE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-9103
Mailing Address - Country:US
Mailing Address - Phone:580-248-1405
Mailing Address - Fax:580-248-8996
Practice Address - Street 1:6302 SW LEE BLVD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-9103
Practice Address - Country:US
Practice Address - Phone:580-248-1405
Practice Address - Fax:580-248-8996
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4219251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK371667Medicare ID - Type UnspecifiedHOSPICE PROVIDER