Provider Demographics
NPI:1356376321
Name:CCCFW, LLC
Entity type:Organization
Organization Name:CCCFW, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROYCE
Authorized Official - Middle Name:
Authorized Official - Last Name:FREEBOURN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:940-220-6440
Mailing Address - Street 1:1714 TEASLEY LN
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76205-7795
Mailing Address - Country:US
Mailing Address - Phone:940-220-6440
Mailing Address - Fax:940-220-6443
Practice Address - Street 1:900 W LEUDA ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-3002
Practice Address - Country:US
Practice Address - Phone:817-332-7003
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00101383Medicaid
TX00101383Medicaid