Healthcare Provider Details

I. General information

NPI: 1174857676
Provider Name (Legal Business Name): WEDGEWOOD SNF LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2009
Last Update Date: 10/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6621 DAN DANCIGER RD
FORT WORTH TX
76133-4905
US

IV. Provider business mailing address

2225 E RANDOL MILL RD SUITE 630
ARLINGTON TX
76011-6315
US

V. Phone/Fax

Practice location:
  • Phone: 817-292-6330
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code332BN1400X
TaxonomyNursing Facility Supplies (DME)
License Number
License Number StateTX

VIII. Authorized Official

Name: ZEVI KOHN
Title or Position: CFO
Credential:
Phone: 718-412-3522