=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164078028
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRUE VINE CONNECTION, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/15/2019
-----------------------------------------------------
Last Update Date | 08/15/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4914 INVERNESS AVE
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76132-1608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 682-203-1239
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4809 ELLSWORTH ST
-----------------------------------------------------
City | MANSFIELD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76063-1898
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 682-203-1239
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MARCUS DUNN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 682-203-1239
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 385HR2060X
-----------------------------------------------------
Taxonomy Name | Child Intellectual and/or Developmental Disabilities Respite Care
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------