Provider Demographics
NPI:1588602676
Name:KB HEALTHCARE, INC
Entity Type:Organization
Organization Name:KB HEALTHCARE, INC
Other - Org Name:VILLAGE CREEK NURSING HOME
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLDT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-429-1991
Mailing Address - Street 1:3825 VILLAGE CREEK RD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76119-2115
Mailing Address - Country:US
Mailing Address - Phone:817-429-1991
Mailing Address - Fax:817-536-5008
Practice Address - Street 1:3825 VILLAGE CREEK RD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76119-2115
Practice Address - Country:US
Practice Address - Phone:817-429-1991
Practice Address - Fax:817-536-5008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX112001314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX675977Medicare ID - Type Unspecified