Provider Demographics
NPI:1053309575
Name:FORT WORTH NURSING & REHABILITATION CENTER
Entity Type:Organization
Organization Name:FORT WORTH NURSING & REHABILITATION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF GENERAL PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DICK
Authorized Official - Middle Name:
Authorized Official - Last Name:STEBBINS
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:903-757-5360
Mailing Address - Street 1:600 E WHALEY ST
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601-6525
Mailing Address - Country:US
Mailing Address - Phone:903-757-5360
Mailing Address - Fax:903-753-8621
Practice Address - Street 1:1000 6TH AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2808
Practice Address - Country:US
Practice Address - Phone:817-336-2586
Practice Address - Fax:817-336-6620
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-10
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX109618314000000X, 332BN1400X, 332BP3500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX000400403Medicaid
TXHO4554608Medicaid
TX094414202Medicaid
TX094414201Medicaid
TX094414202Medicaid
TX0633640001Medicare NSC