Healthcare Provider Details

I. General information

NPI: 1396921656
Provider Name (Legal Business Name): FABOS COMMUNITY INTERSECTION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2008
Last Update Date: 01/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

924 MARION AVE
FORT WORTH TX
76104-6537
US

IV. Provider business mailing address

PO BOX 5133
ARLINGTON TX
76005-5133
US

V. Phone/Fax

Practice location:
  • Phone: 817-987-7634
  • Fax:
Mailing address:
  • Phone: 817-987-7634
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MS. EUNICE FUNKE AKINGBADE
Title or Position: MANAGING
Credential:
Phone: 817-987-7634