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NPI Code Detail

MEDICARE: FORT WORTH III ENTERPRISES, LLC

MEDICARE: FORT WORTH III ENTERPRISES, 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
1314000000XSkilled Nursing Facility

General Provider Information

NPI Number : 1679296735
Entity Type Code : Organization
Provider Name (Legal Business Name) : FORT WORTH III ENTERPRISES, LLC
Provider Business Mailing Address
First Line : 4150 INTERNATIONAL PLZ STE 600
Second Line :
City : FORT WORTH
State : TX
Zip : 76109-4831
Country : US
Telephone Number : 817-348-8959
Fax Number :
Provider Business Practice Location Address
First Line : 4825 WELLESLEY AVE
Second Line :
City : FORT WORTH
State : TX
Zip : 76107-6148
Country : US
Telephone Number : 817-732-6608
Fax Number :
Authorized Official
Title or Position : MANAGING MEMBER
Name : GARY BLAKE
Credential :
Telephone Number : 817-348-8959
Provider Enumeration Date : 09/23/2022
Last Update Date : 09/23/2022

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Directions to “FORT WORTH III ENTERPRISES, LLC ” Practice Location

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