Provider Demographics
NPI:1811453079
Name:SSC FORT WORTH NURSING & REHABILITATION CENTER OPERATING COMPANY LLC
Entity type:Organization
Organization Name:SSC FORT WORTH NURSING & REHABILITATION CENTER OPERATING COMPANY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SR DIRECTOR A/R
Authorized Official - Prefix:
Authorized Official - First Name:KELLE
Authorized Official - Middle Name:C
Authorized Official - Last Name:SANTORO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-467-5728
Mailing Address - Street 1:5300 W SAM HOUSTON PKWY N STE 100
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77041-5162
Mailing Address - Country:US
Mailing Address - Phone:832-467-5728
Mailing Address - Fax:832-467-8500
Practice Address - Street 1:4825 WELLESLEY AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-6148
Practice Address - Country:US
Practice Address - Phone:817-732-4714
Practice Address - Fax:817-735-4118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-13
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001028825Medicaid