Provider Demographics
NPI:1689842536
Name:HERITAGE HOSPICE OF TEXARKANA LLC
Entity type:Organization
Organization Name:HERITAGE HOSPICE OF TEXARKANA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, CEO
Authorized Official - Prefix:
Authorized Official - First Name:BLAKE
Authorized Official - Middle Name:
Authorized Official - Last Name:RICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-792-0716
Mailing Address - Street 1:4605 TEXAS BLVD
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-3028
Mailing Address - Country:US
Mailing Address - Phone:903-792-0716
Mailing Address - Fax:903-792-0719
Practice Address - Street 1:4605 TEXAS BLVD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-3028
Practice Address - Country:US
Practice Address - Phone:903-792-0716
Practice Address - Fax:903-792-0719
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX012655251G00000X, 251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001018745Medicaid
TX001018745Medicaid