MEDICARE: CIVITAS SENIOR HEALTHCARE, 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
1	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1942888953
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CIVITAS SENIOR HEALTHCARE, LLC

Provider Business Mailing Address
First Line	:	930 W 1ST ST STE 400
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76102-2743
Country	:	US
Telephone Number	:	817-386-8888
Fax Number	:

Provider Business Practice Location Address
First Line	:	930 W 1ST ST STE 400
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76102-2743
Country	:	US
Telephone Number	:	817-386-8888
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	COOPER VITTITOW
Credential	:
Telephone Number	:	817-454-5561

Provider Enumeration Date	:	03/31/2021
Last Update Date	:	03/31/2021

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