Provider Demographics
NPI:1316941818
Name:GRACE HOSPICE, LLC
Entity type:Organization
Organization Name:GRACE HOSPICE, LLC
Other - Org Name:<UNAVAIL>
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:972-424-3454
Mailing Address - Street 1:730 AVENUE F
Mailing Address - Street 2:STE 200
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75074-6752
Mailing Address - Country:US
Mailing Address - Phone:972-424-3454
Mailing Address - Fax:972-424-3054
Practice Address - Street 1:730 AVENUE F
Practice Address - Street 2:STE 200
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75074-6752
Practice Address - Country:US
Practice Address - Phone:972-424-3454
Practice Address - Fax:972-424-3054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-13
Last Update Date:2017-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX009334251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001004614Medicaid
TX451723Medicare ID - Type UnspecifiedMEDICARE