Provider Demographics
NPI:1417294661
Name:AWAL 2012 OPCO, LLC
Entity Type:Organization
Organization Name:AWAL 2012 OPCO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:POWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-386-8888
Mailing Address - Street 1:1004 E COKE RD
Mailing Address - Street 2:
Mailing Address - City:WINNSBORO
Mailing Address - State:TX
Mailing Address - Zip Code:75494-3536
Mailing Address - Country:US
Mailing Address - Phone:817-386-8888
Mailing Address - Fax:817-549-0020
Practice Address - Street 1:3801 HULEN ST
Practice Address - Street 2:SUITE 202
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-7202
Practice Address - Country:US
Practice Address - Phone:817-386-8888
Practice Address - Fax:817-549-0020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-08
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX104275310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility