Provider Demographics
NPI:1548359144
Name:BRENTWOOD HOSPICE, LLC
Entity type:Organization
Organization Name:BRENTWOOD HOSPICE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:CALLOWAY
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:903-681-7406
Mailing Address - Street 1:600 E WHALEY ST
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601-6525
Mailing Address - Country:US
Mailing Address - Phone:903-230-7670
Mailing Address - Fax:903-230-7696
Practice Address - Street 1:1250 E COPELAND RD STE 260
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76011-1345
Practice Address - Country:US
Practice Address - Phone:214-275-6200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX010526251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001015314Medicaid
TX671563Medicare UPIN