Healthcare Provider Details

I. General information

NPI: 1346592029
Provider Name (Legal Business Name): FCI FORT WORTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2012
Last Update Date: 10/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3150 HORTON RD
FOREST HILL TX
76119-5905
US

IV. Provider business mailing address

3150 HORTON RD
FOREST HILL TX
76119-5905
US

V. Phone/Fax

Practice location:
  • Phone: 817-534-8400
  • Fax:
Mailing address:
  • Phone: 817-534-8400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number
License Number StateTX

VIII. Authorized Official

Name: VERONICA KAETHER
Title or Position: SCS
Credential:
Phone: 817-534-8400