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NPI Code Detail

MEDICARE: TICKNOR ENTERPRISES STEPHENVILLE, LLC

MEDICARE: TICKNOR ENTERPRISES STEPHENVILLE, LLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1314000000XSkilled Nursing Facility

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1004051OTHERTXDADS FACILITY ID

General Provider Information

NPI Number : 1063760361
Entity Type Code : Organization
Provider Name (Legal Business Name) : TICKNOR ENTERPRISES STEPHENVILLE, LLC
Provider Business Mailing Address
First Line : 4150 INTERNATIONAL PLAZA
Second Line : SUITE 102
City : FORT WORTH
State : TX
Zip : 76109-4846
Country : US
Telephone Number : 682-305-7150
Fax Number : 682-318-1799
Provider Business Practice Location Address
First Line : 2311 WEST WASHINGTON STREET
Second Line :
City : STEPHENVILLE
State : TX
Zip : 76401-3805
Country : US
Telephone Number : 254-968-3313
Fax Number : 682-305-7155
Authorized Official
Title or Position : MANAGER
Name : MR. LEON EVANS
Credential :
Telephone Number : 682-305-7150
Provider Enumeration Date : 08/17/2012
Last Update Date : 12/02/2025

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Directions to “TICKNOR ENTERPRISES STEPHENVILLE, LLC ” Practice Location

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