Provider Demographics
NPI:1336119619
Name:COOK CHILDRENS HOME HEALTH
Entity Type:Organization
Organization Name:COOK CHILDRENS HOME HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:682-885-2409
Mailing Address - Street 1:PO BOX 99283
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76199-1383
Mailing Address - Country:US
Mailing Address - Phone:682-885-6294
Mailing Address - Fax:682-885-1135
Practice Address - Street 1:1101 W VICKERY BLVD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-1025
Practice Address - Country:US
Practice Address - Phone:682-885-6294
Practice Address - Fax:682-885-1135
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COOK CHILDREN'S HOME HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-01-26
Last Update Date:2021-12-02
Deactivation Date:2007-02-26
Deactivation Code:
Reactivation Date:2008-11-26
Provider Licenses
StateLicense IDTaxonomies
251E00000X
TX007555251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX024794201Medicaid
TX024794203/CSNMedicaid
TX024794203/CSNMedicaid
TX024794201MedicaidINDIVIDUAL TPI NUMBER