Basic Information
| Provider Information | |||||||||
| NPI: | 1215174727 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TANDY VILLAGE ASSISTED LIVING | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | ROMANS HOUSE LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2601 TANDY AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761032552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8175351253 | ||||||||
| FaxNumber: | 8175360177 | ||||||||
| Practice Location | |||||||||
| Address1: | 2601 TANDY AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761032552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8175351253 | ||||||||
| FaxNumber: | 8175360177 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/21/2009 | ||||||||
| LastUpdateDate: | 01/21/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | QUETON | ||||||||
| AuthorizedOfficialFirstName: | NELLIE | ||||||||
| AuthorizedOfficialMiddleName: | S. | ||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8175351253 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | 125808 | TX | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | 000964 | 01 | TX | TEXAS DEPT OF AGING AND DISABILITY- DADS | OTHER |