Healthcare Provider Details

I. General information

NPI: 1457329658
Provider Name (Legal Business Name): CENTER FOR LONG TERM CARE OF WOODRIDGE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 AUTUMN DR
GRAPEVINE TX
76051-3103
US

IV. Provider business mailing address

PO BOX 155635
FORT WORTH TX
76155-0635
US

V. Phone/Fax

Practice location:
  • Phone: 817-488-8585
  • Fax: 817-488-7298
Mailing address:
  • Phone: 817-359-2000
  • Fax: 817-359-2093

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: GARY R TREBERT
Title or Position: CEO
Credential:
Phone: 817-359-2000