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General NPI Number Information
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NPI Number | 1023605730
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Entity Type | Organization
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Legal Business Name | SLP FORT WORTH LLC
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Dates
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Enumeration Date | 12/29/2020
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Last Update Date | 12/29/2020
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Provider Practice Location Address
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Address Line | 701 SAINT LOUIS AVE
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City | FORT WORTH
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State | TX
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Zip | 76104-3324
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Country | US
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Telephone | 817-332-9962
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Fax | 817-332-9252
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Provider Business Mailing Address
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Address Line | 701 SAINT LOUIS AVE
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City | FORT WORTH
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State | TX
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Zip | 76104-3324
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Country | US
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Telephone | 817-332-9962
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Fax | 817-332-9252
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Authorized Official
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Title or Position | CEO
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Name | CASSANDRA MISTRETTA
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Credential |
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Telephone | 817-410-7300
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number |
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License Number State |
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