Healthcare Provider Details

I. General information

NPI: 1285935650
Provider Name (Legal Business Name): FORT WORTH WEST SIDE LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2010
Last Update Date: 01/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 S LAS VEGAS TRL
WHITE SETTLEMENT TX
76108-3350
US

IV. Provider business mailing address

600 E WHALEY ST
LONGVIEW TX
75601-6525
US

V. Phone/Fax

Practice location:
  • Phone: 817-246-4995
  • Fax:
Mailing address:
  • Phone: 903-757-5360
  • Fax: 903-753-8621

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: DR. DICK STEBBINS
Title or Position: MANAGER OF GENERAL PARTNER
Credential:
Phone: 903-757-5360