Provider Demographics
NPI:1477674968
Name:FANNIN COUNTY HOSPITAL AUTHORITY
Entity Type:Organization
Organization Name:FANNIN COUNTY HOSPITAL AUTHORITY
Other - Org Name:INTERLOCHEN HEALTH AND REHABILTATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BOARD PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CLARK
Authorized Official - Middle Name:
Authorized Official - Last Name:SANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-583-1854
Mailing Address - Street 1:4150 INTERNATIONAL PLZ STE 600
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-4831
Mailing Address - Country:US
Mailing Address - Phone:817-348-8959
Mailing Address - Fax:817-348-0466
Practice Address - Street 1:2645 W RANDOL MILL RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76012-4228
Practice Address - Country:US
Practice Address - Phone:817-277-6789
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX114501314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1028814Medicaid
TX455835Medicare Oscar/Certification