Basic Information
| Provider Information | |||||||||
| NPI: | 1457950628 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WATAUGA I ENTERPRISES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4150 INTERNATIONAL PLZ STE 600 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761094831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173488959 | ||||||||
| FaxNumber: | 8173480466 | ||||||||
| Practice Location | |||||||||
| Address1: | 7804 VIRGIL ANTHONY BLVD | ||||||||
| Address2: | |||||||||
| City: | WATAUGA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761482456 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174987220 | ||||||||
| FaxNumber: | 8175000108 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2020 | ||||||||
| LastUpdateDate: | 10/20/2020 | ||||||||
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| AuthorizedOfficialLastName: | HUGGINS | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP OF ACCOUNTS RECEIVABLE | ||||||||
| AuthorizedOfficialTelephone: | 8173488959 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.