Basic Information
| Provider Information | |||||||||
| NPI: | 1285935650 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FORT WORTH WEST SIDE LTD | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | WEST SIDE CAMPUS OF CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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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: | 1950 S LAS VEGAS TRL | ||||||||
| Address2: | |||||||||
| City: | WHITE SETTLEMENT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761083350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8172464995 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2010 | ||||||||
| LastUpdateDate: | 01/03/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | STEBBINS | ||||||||
| AuthorizedOfficialFirstName: | DICK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER OF GENERAL PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 9037575360 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 5204 | 05 | TX | MEDICAID |