Healthcare Provider Details

I. General information

NPI: 1669771366
Provider Name (Legal Business Name): AMITY FELLOWSERVE OF MIDLAND, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2011
Last Update Date: 11/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3203 SAGE ST
MIDLAND TX
79705-5711
US

IV. Provider business mailing address

5228 VALLEYPOINTE PKWY BLDG. B, SUITE 1
ROANOKE VA
24019-3074
US

V. Phone/Fax

Practice location:
  • Phone: 432-683-5403
  • Fax: 432-682-5105
Mailing address:
  • Phone: 540-265-0322
  • Fax: 540-265-0305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number132737
License Number StateTX

VIII. Authorized Official

Name: THOMAS CLARKE
Title or Position: CEO
Credential:
Phone: 540-265-0322