MEDICARE: FORT WORTH WEST SIDE LTD

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	314000000X	Skilled Nursing Facility

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

General Provider Information

NPI Number	:	1285935650
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FORT WORTH WEST SIDE LTD

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	:	1950 S LAS VEGAS TRL
Second Line	:
City	:	WHITE SETTLEMENT
State	:	TX
Zip	:	76108-3350
Country	:	US
Telephone Number	:	817-246-4995
Fax Number	:

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

Provider Enumeration Date	:	11/16/2010
Last Update Date	:	01/03/2011

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Directions to “FORT WORTH WEST SIDE LTD ” Practice Location

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