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General NPI Number Information
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NPI Number | 1225338684
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Entity Type | Organization
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Legal Business Name | KINGSBROOK SENIOR CARE
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Dates
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Enumeration Date | 11/01/2010
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Last Update Date | 01/31/2013
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Provider Practice Location Address
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Address Line | 521 E BOLT ST
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City | FORT WORTH
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State | TX
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Zip | 76110-6310
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Country | US
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Telephone | 817-202-5752
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Fax |
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Provider Business Mailing Address
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Address Line | 1921 KINGSBROOK TRL
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City | FORT WORTH
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State | TX
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Zip | 76120-5081
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | MRS. TEMITAYO SODIMU
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Credential | NURSE PRACTITIONER
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Telephone | 817-202-5752
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 253Z00000X
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Taxonomy Name | In Home Supportive Care Agency
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License Number |
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License Number State |
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