MEDICARE: FORT WORTH NURSING & REHABILITATION CENTER

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	332BP3500X	Parenteral & Enteral Nutrition Supplies (DME)	109618	TX
2	332BN1400X	Nursing Facility Supplies (DME)	109618	TX
3	314000000X	Skilled Nursing Facility	109618	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1053309575
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FORT WORTH NURSING & REHABILITATION CENTER

Provider Business Mailing Address
First Line	:	600 E WHALEY ST
Second Line	:
City	:	LONGVIEW
State	:	TX
Zip	:	75601-6525
Country	:	US
Telephone Number	:	903-757-5360
Fax Number	:	903-753-8621

Provider Business Practice Location Address
First Line	:	1000 6TH AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-2808
Country	:	US
Telephone Number	:	817-336-2586
Fax Number	:	817-336-6620

Authorized Official
Title or Position	:	PRESIDENT OF GENERAL PARTNER
Name	:	MR. DICK STEBBINS
Credential	:	CPA
Telephone Number	:	903-757-5360

Provider Enumeration Date	:	10/10/2005
Last Update Date	:	06/25/2008

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Directions to “FORT WORTH NURSING & REHABILITATION CENTER ” Practice Location

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