1588725592 NPI number — FWM HEALTHCARE, LLC DBA FT. WORTH MANOR

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588725592 NPI number — FWM HEALTHCARE, LLC DBA FT. WORTH MANOR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FWM HEALTHCARE, LLC DBA FT. WORTH MANOR
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1588725592
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2712 HURSTVIEW DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HURST
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76054-2402
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-514-2203
Provider Business Mailing Address Fax Number:
817-281-6717

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4900 E BERRY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FT WORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76105-4314
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-531-3707
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SUTTON
Authorized Official First Name:
AL
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
817-514-2203

Provider Taxonomy Codes

  • Taxonomy code: 313M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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