1962423871 NPI number — FIRESIDE LODGE RETIREMENT CENTER INC

Table of content: (NPI 1962423871)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962423871 NPI number — FIRESIDE LODGE RETIREMENT CENTER INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FIRESIDE LODGE RETIREMENT CENTER INC
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:
1962423871
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:
4800 WHITE SETTLEMENT RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76114-3955
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-738-6556
Provider Business Mailing Address Fax Number:
817-738-6559

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4800 WHITE SETTLEMENT RD
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:
76114-3955
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-738-6556
Provider Business Practice Location Address Fax Number:
817-738-6559
Provider Enumeration Date:
07/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MCGRATH
Authorized Official First Name:
TERRY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
817-738-6556

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  117321 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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