Provider Demographics
NPI:1972665420
Name:TEXAS BLUEBONNET HOME CARE INC
Entity Type:Organization
Organization Name:TEXAS BLUEBONNET HOME CARE INC
Other - Org Name:BLUEBONNET HOME CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR CEO
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:M
Authorized Official - Last Name:FETTINGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-275-1040
Mailing Address - Street 1:3613 W PIONEER PKWY STE B
Mailing Address - Street 2:
Mailing Address - City:PANTEGO
Mailing Address - State:TX
Mailing Address - Zip Code:76013-4517
Mailing Address - Country:US
Mailing Address - Phone:903-763-2058
Mailing Address - Fax:903-763-2067
Practice Address - Street 1:211 N NEWSOM ST
Practice Address - Street 2:SUITE A
Practice Address - City:MINEOLA
Practice Address - State:TX
Practice Address - Zip Code:75773-2133
Practice Address - Country:US
Practice Address - Phone:903-763-2058
Practice Address - Fax:903-763-2067
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2010-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX009709251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX181840301Medicaid
TX677833Medicare Oscar/Certification