Healthcare Provider Details

I. General information

NPI: 1528504529
Provider Name (Legal Business Name): FPACP UPSHUR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2017
Last Update Date: 05/06/2021
Certification Date: 05/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

623 STATE HIGHWAY 155 N
GILMER TX
75644-5725
US

IV. Provider business mailing address

1401 BALLINGER ST
FORT WORTH TX
76102-5903
US

V. Phone/Fax

Practice location:
  • Phone: 903-797-2143
  • Fax: 903-797-2725
Mailing address:
  • Phone: 817-632-1000
  • Fax: 817-632-1001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number StateTX

VIII. Authorized Official

Name: MR. MARK MCKENZIE
Title or Position: MANAGER
Credential:
Phone: 817-632-1000