MEDICARE: PCI ADULT DAYCARE, 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	261QA0600X	Adult Day Care Clinic/Center	138023	TX

General Provider Information

NPI Number	:	1730593476
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PCI ADULT DAYCARE, LLC

Provider Business Mailing Address
First Line	:	6050 HARRIS PKWY
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76132-4102
Country	:	US
Telephone Number	:	817-921-9500
Fax Number	:	817-921-9576

Provider Business Practice Location Address
First Line	:	6050 HARRIS PKWY
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76132-4102
Country	:	US
Telephone Number	:	817-921-9500
Fax Number	:	817-921-9576

Authorized Official
Title or Position	:	CFO
Name	:	MR. HOWARD DON PETERSEN
Credential	:	CPA
Telephone Number	:	817-637-9100

Provider Enumeration Date	:	06/19/2014
Last Update Date	:	06/19/2014

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