Healthcare Provider Details

I. General information

NPI: 1720943343
Provider Name (Legal Business Name): HEALING HAVEN HOMES AT LAKE COUNTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2025
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7505 LOCHWOOD CT
FORT WORTH TX
76179-3137
US

IV. Provider business mailing address

7505 LOCHWOOD CT
FORT WORTH TX
76179-3137
US

V. Phone/Fax

Practice location:
  • Phone: 703-554-7829
  • Fax: 469-397-0779
Mailing address:
  • Phone: 703-554-7829
  • Fax: 469-397-0779

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: MABEL WIBA NIKOI
Title or Position: ADMINISTRATOR
Credential:
Phone: 703-554-7829