Healthcare Provider Details

I. General information

NPI: 1053309575
Provider Name (Legal Business Name): FORT WORTH NURSING & REHABILITATION CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2005
Last Update Date: 06/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 6TH AVE
FORT WORTH TX
76104-2808
US

IV. Provider business mailing address

600 E WHALEY ST
LONGVIEW TX
75601-6525
US

V. Phone/Fax

Practice location:
  • Phone: 817-336-2586
  • Fax: 817-336-6620
Mailing address:
  • Phone: 903-757-5360
  • Fax: 903-753-8621

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number109618
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code332BN1400X
TaxonomyNursing Facility Supplies (DME)
License Number109618
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number109618
License Number StateTX

VIII. Authorized Official

Name: MR. DICK STEBBINS
Title or Position: PRESIDENT OF GENERAL PARTNER
Credential: CPA
Phone: 903-757-5360