MEDICARE: ABLECARE GROUP HOME 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	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility	32090000X	TX

General Provider Information

NPI Number	:	1427405083
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ABLECARE GROUP HOME LLC

Provider Business Mailing Address
First Line	:	2533 MILL SPRINGS PASS
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76123-2615
Country	:	US
Telephone Number	:	817-443-8775
Fax Number	:

Provider Business Practice Location Address
First Line	:	2533 MILL SPRINGS PASS
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76123-2615
Country	:	US
Telephone Number	:	817-443-8775
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	MRS. MICHELE D GRAHAM
Credential	:	RN,BSN
Telephone Number	:	817-443-8775

Provider Enumeration Date	:	05/24/2016
Last Update Date	:	05/24/2016

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