MEDICARE: CARE KING LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility

General Provider Information

NPI Number	:	1023317187
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CARE KING LLC

Provider Business Mailing Address
First Line	:	1129 FAIRWEATHER DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76120-3325
Country	:	US
Telephone Number	:	817-510-7741
Fax Number	:

Provider Business Practice Location Address
First Line	:	1129 FAIRWEATHER DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76120-3325
Country	:	US
Telephone Number	:	817-510-7741
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. JERRY GREEN
Credential	:
Telephone Number	:	817-510-7741

Provider Enumeration Date	:	03/15/2011
Last Update Date	:	08/21/2013

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