=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891947040
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AG HOSPICE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/21/2008
-----------------------------------------------------
Last Update Date | 08/23/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16420 PARK TEN PL STE 240
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77084-5299
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-437-2089
-----------------------------------------------------
Fax | 832-437-2090
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 717 N HARWOOD ST STE 550
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75201-6540
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-628-9951
-----------------------------------------------------
Fax | 214-389-0976
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT & CEO
-----------------------------------------------------
Name | ANDREA BOHANNON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 214-628-9950
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251G00000X
-----------------------------------------------------
Taxonomy Name | Community Based Hospice Care Agency
-----------------------------------------------------
License Number | 12501
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------