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General NPI Number Information
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NPI Number | 1053309575
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Entity Type | Organization
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Legal Business Name | FORT WORTH NURSING & REHABILITATION CENTER
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Dates
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Enumeration Date | 10/10/2005
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Last Update Date | 06/25/2008
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Provider Practice Location Address
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Address Line | 1000 6TH AVE
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City | FORT WORTH
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State | TX
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Zip | 76104-2808
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Country | US
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Telephone | 817-336-2586
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Fax | 817-336-6620
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Provider Business Mailing Address
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Address Line | 600 E WHALEY ST
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City | LONGVIEW
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State | TX
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Zip | 75601-6525
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Country | US
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Telephone | 903-757-5360
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Fax | 903-753-8621
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Authorized Official
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Title or Position | PRESIDENT OF GENERAL PARTNER
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Name | MR. DICK STEBBINS
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Credential | CPA
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Telephone | 903-757-5360
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332BP3500X
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Taxonomy Name | Parenteral & Enteral Nutrition Supplies (DME)
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License Number | 109618
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 332BN1400X
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Taxonomy Name | Nursing Facility Supplies (DME)
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License Number | 109618
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License Number State | TX
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Taxonomy #3
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number | 109618
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License Number State | TX
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