=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295253052
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | S TCG BENBROOK AL, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2017
-----------------------------------------------------
Last Update Date | 09/13/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4242 BRYANT IRVIN RD
-----------------------------------------------------
City | BENBROOK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76109-4222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-763-0088
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 801 CHERRY ST STE 2400
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76102-6824
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MICHAEL HALL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 214-616-5001
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------