MEDICARE: ST. JOHN'S RESIDENTIAL CARE HOME INC.

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	:	1437997731
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST. JOHN'S RESIDENTIAL CARE HOME INC.

Provider Business Mailing Address
First Line	:	4448 MALLOW OAK DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76123-2734
Country	:	US
Telephone Number	:	817-361-0559
Fax Number	:	817-361-9244

Provider Business Practice Location Address
First Line	:	4448 MALLOW OAK DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76123-2734
Country	:	US
Telephone Number	:	817-361-0559
Fax Number	:	817-361-9244

Authorized Official
Title or Position	:	OWNER, CEO, PRESIDENT
Name	:	JUDITH TAN-PASCUAL
Credential	:	RN, BSN
Telephone Number	:	817-680-5171

Provider Enumeration Date	:	07/19/2024
Last Update Date	:	07/19/2024

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