=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467973404
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOC FORT WORTH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/29/2017
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6301 OAKMONT BLVD
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76132-2814
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-277-3345
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1101 ARROW POINT DR STE 210
-----------------------------------------------------
City | CEDAR PARK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78613-7739
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-277-3345
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MARK FRITZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 512-277-3345
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------