Provider Demographics
NPI:1700892593
Name:CENTERS FOR LONG TERM CARE ANCILLARY SERVICES INC.
Entity Type:Organization
Organization Name:CENTERS FOR LONG TERM CARE ANCILLARY SERVICES INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:R
Authorized Official - Last Name:TREBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-634-0868
Mailing Address - Street 1:7606 PEBBLE DR
Mailing Address - Street 2:BLDG 28
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76118-6994
Mailing Address - Country:US
Mailing Address - Phone:214-624-0868
Mailing Address - Fax:817-358-1080
Practice Address - Street 1:7606 PEBBLE DR
Practice Address - Street 2:BLDG 28
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76118-6994
Practice Address - Country:US
Practice Address - Phone:214-624-0868
Practice Address - Fax:817-595-8929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0052443332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00939232AMedicaid
IA0548974Medicaid
NM75033020Medicaid
GA00939232AMedicaid
TX4296030001Medicare NSC