- Enrollment id
- O20120907000410
- Enrollment state
- TX
- Provider type code
- 00-08
- Provider type text
- PART A PROVIDER - HOSPICE
- Npi
- 1174840151
- Multiple npi flag
- N
- Ccn
- A91628
- Associate id
- 4880842335
- Organization name
- COVENANT GRACE HOSPICE, INC.
- Doing business as name
- FAIRMONT HOSPICE
- Incorporation date
- 2009-09-10
- Incorporation state
- TX
- Organization type structure
- CORPORATION
- Proprietary nonprofit
- P
- Address line 1
- 300 JACKSON ST
- City
- RICHMOND
- State
- TX
- Zip code
- 774693109