MEDICARE: FT. WORTH HOME CARE 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	253Z00000X	In Home Supportive Care Agency	012106	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	012106	OTHER	TX	DADS

General Provider Information

NPI Number	:	1629499900
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FT. WORTH HOME CARE INC

Provider Business Mailing Address
First Line	:	1600 AIRPORT FWY
Second Line	:	SUITE 503
City	:	BEDFORD
State	:	TX
Zip	:	76022-6850
Country	:	US
Telephone Number	:	817-283-4488
Fax Number	:	817-283-4499

Provider Business Practice Location Address
First Line	:	1600 AIRPORT FWY
Second Line	:	SUITE 503
City	:	BEDFORD
State	:	TX
Zip	:	76022-6850
Country	:	US
Telephone Number	:	817-283-4488
Fax Number	:	817-283-4499

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MS. LAURIE D GILLESPIE
Credential	:
Telephone Number	:	817-283-4488

Provider Enumeration Date	:	01/03/2014
Last Update Date	:	01/03/2014

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