Basic Information
| Provider Information | |||||||||
| NPI: | 1811453079 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SSC FORT WORTH NURSING & REHABILITATION CENTER OPERATING COMPANY LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ARLINGTON HEIGHTS HEALTH AND REHABILITATION CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5300 W SAM HOUSTON PKWY N STE 100 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770415162 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8324675728 | ||||||||
| FaxNumber: | 8324678500 | ||||||||
| Practice Location | |||||||||
| Address1: | 4825 WELLESLEY AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761076148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177324714 | ||||||||
| FaxNumber: | 8177354118 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2019 | ||||||||
| LastUpdateDate: | 11/16/2020 | ||||||||
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| AuthorizedOfficialLastName: | SANTORO | ||||||||
| AuthorizedOfficialFirstName: | KELLE | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | SR DIRECTOR A/R | ||||||||
| AuthorizedOfficialTelephone: | 8324675728 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/16/2020 | ||||||||
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 | 001028825 | 05 | TX | MEDICAID |