Provider Demographics
NPI:1215174727
Name:TANDY VILLAGE ASSISTED LIVING
Entity type:Organization
Organization Name:TANDY VILLAGE ASSISTED LIVING
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:NELLIE
Authorized Official - Middle Name:S
Authorized Official - Last Name:QUETON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-535-1253
Mailing Address - Street 1:2601 TANDY AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76103-2552
Mailing Address - Country:US
Mailing Address - Phone:817-535-1253
Mailing Address - Fax:817-536-0177
Practice Address - Street 1:2601 TANDY AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76103-2552
Practice Address - Country:US
Practice Address - Phone:817-535-1253
Practice Address - Fax:817-536-0177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-21
Last Update Date:2009-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX125808310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX000964OtherTEXAS DEPT OF AGING AND DISABILITY- DADS