Healthcare Provider Details

I. General information

NPI: 1992976351
Provider Name (Legal Business Name): MSPF-IV GRAPEVINE OE, LP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2008
Last Update Date: 04/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 IRA E WOODS AVE
GRAPEVINE TX
76051-4018
US

IV. Provider business mailing address

3811 TURTLE CREEK BLVD SUITE #1850
DALLAS TX
75219-4402
US

V. Phone/Fax

Practice location:
  • Phone: 817-796-4621
  • Fax: 817-796-4629
Mailing address:
  • Phone: 214-651-4050
  • Fax: 214-651-4001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number117706
License Number StateTX

VIII. Authorized Official

Name: MR. DAVID RONCK
Title or Position: MANAGER
Credential:
Phone: 214-651-4050