MEDICARE: RICKY'S HCS PLACE, 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	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1861767493
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RICKY'S HCS PLACE, INC

Provider Business Mailing Address
First Line	:	12001 WALDEN WOOD DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76244-5571
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	12001 WALDEN WOOD DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76244-5571
Country	:	US
Telephone Number	:	817-562-2692
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MRS. SYBIL ZIEGLER
Credential	:
Telephone Number	:	817-562-2692

Provider Enumeration Date	:	03/15/2012
Last Update Date	:	03/19/2012

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