Basic Information
| Provider Information | |||||||||
| NPI: | 1053309575 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FORT WORTH NURSING & REHABILITATION CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 E WHALEY ST | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | TX | ||||||||
| PostalCode: | 756016525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9037575360 | ||||||||
| FaxNumber: | 9037538621 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 6TH AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761042808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173362586 | ||||||||
| FaxNumber: | 8173366620 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2005 | ||||||||
| LastUpdateDate: | 06/25/2008 | ||||||||
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| AuthorizedOfficialLastName: | STEBBINS | ||||||||
| AuthorizedOfficialFirstName: | DICK | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT OF GENERAL PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 9037575360 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | CPA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BP3500X | 109618 | TX | N | Suppliers | Durable Medical Equipment & Medical Supplies | Parenteral & Enteral Nutrition | 332BN1400X | 109618 | TX | N | Suppliers | Durable Medical Equipment & Medical Supplies | Nursing Facility Supplies | 314000000X | 109618 | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 000400403 | 05 | TX | MEDICAID | HO4554608 | 05 | TX | MEDICAID | 094414202 | 05 | TX | MEDICAID | 094414201 | 05 | TX | MEDICAID |