Healthcare Provider Details

I. General information

NPI: 1942888953
Provider Name (Legal Business Name): CIVITAS SENIOR HEALTHCARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2021
Last Update Date: 03/31/2021
Certification Date: 03/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

930 W 1ST ST STE 400
FORT WORTH TX
76102-2743
US

IV. Provider business mailing address

930 W 1ST ST STE 400
FORT WORTH TX
76102-2743
US

V. Phone/Fax

Practice location:
  • Phone: 817-386-8888
  • Fax:
Mailing address:
  • Phone: 817-386-8888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: COOPER VITTITOW
Title or Position: PRESIDENT
Credential:
Phone: 817-454-5561