Provider Demographics
NPI:1063760361
Name:TICKNOR ENTERPRISES STEPHENVILLE, LLC
Entity type:Organization
Organization Name:TICKNOR ENTERPRISES STEPHENVILLE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:LEON
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:682-305-7150
Mailing Address - Street 1:4150 INTERNATIONAL PLAZA
Mailing Address - Street 2:SUITE 102
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-4846
Mailing Address - Country:US
Mailing Address - Phone:682-305-7150
Mailing Address - Fax:682-318-1799
Practice Address - Street 1:2311 WEST WASHINGTON STREET
Practice Address - Street 2:
Practice Address - City:STEPHENVILLE
Practice Address - State:TX
Practice Address - Zip Code:76401-3805
Practice Address - Country:US
Practice Address - Phone:254-968-3313
Practice Address - Fax:682-305-7155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-17
Last Update Date:2025-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX004051OtherDADS FACILITY ID
TX004051OtherDADS FACILITY ID