Provider Demographics
NPI:1346592029
Name:FCI FORT WORTH
Entity Type:Organization
Organization Name:FCI FORT WORTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SCS
Authorized Official - Prefix:
Authorized Official - First Name:VERONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:KAETHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-534-8400
Mailing Address - Street 1:3150 HORTON RD
Mailing Address - Street 2:
Mailing Address - City:FOREST HILL
Mailing Address - State:TX
Mailing Address - Zip Code:76119-5905
Mailing Address - Country:US
Mailing Address - Phone:817-534-8400
Mailing Address - Fax:
Practice Address - Street 1:3150 HORTON RD
Practice Address - Street 2:
Practice Address - City:FOREST HILL
Practice Address - State:TX
Practice Address - Zip Code:76119-5905
Practice Address - Country:US
Practice Address - Phone:817-534-8400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-05
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization