MEDICARE: GRIFFIN MANOR

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	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1174816912
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRIFFIN MANOR

Provider Business Mailing Address
First Line	:	1428 QUEENS BROOK LN
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76140-5747
Country	:	US
Telephone Number	:	682-433-6070
Fax Number	:	817-568-1486

Provider Business Practice Location Address
First Line	:	1428 QUEENS BROOK LN
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76140-5747
Country	:	US
Telephone Number	:	682-433-6070
Fax Number	:	817-568-1486

Authorized Official
Title or Position	:	OWNER/CARE GIVER
Name	:	MS. JEAN L DEAR
Credential	:
Telephone Number	:	682-433-6070

Provider Enumeration Date	:	05/26/2011
Last Update Date	:	05/26/2011

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Directions to “GRIFFIN MANOR ” Practice Location

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