MEDICARE: HEALING HAVEN HOMES AT LAKE COUNTRY

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	:	1720943343
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEALING HAVEN HOMES AT LAKE COUNTRY

Provider Business Mailing Address
First Line	:	7505 LOCHWOOD CT
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76179-3137
Country	:	US
Telephone Number	:	703-554-7829
Fax Number	:	469-397-0779

Provider Business Practice Location Address
First Line	:	7505 LOCHWOOD CT
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76179-3137
Country	:	US
Telephone Number	:	703-554-7829
Fax Number	:	469-397-0779

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MABEL WIBA NIKOI
Credential	:
Telephone Number	:	703-554-7829

Provider Enumeration Date	:	12/16/2025
Last Update Date	:	12/16/2025

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