=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043450950
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GOOD SAMARITAN SOCIETY HCBS-TX, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2009
-----------------------------------------------------
Last Update Date | 11/01/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 607 W MAGNOLIA AVE STE 205
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76104-4608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-686-4366
-----------------------------------------------------
Fax | 972-686-4372
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 700 N TOWN EAST BLVD APT 159
-----------------------------------------------------
City | MESQUITE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75150-4793
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-686-4366
-----------------------------------------------------
Fax | 972-686-4372
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | TREASURER
-----------------------------------------------------
Name | MR. GEORGE GRANT TRIBBLE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 605-362-3900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------