Provider Demographics
NPI:1316112261
Name:WEST LPN FORT WORTH ONCOLOGY PLLC
Entity type:Organization
Organization Name:WEST LPN FORT WORTH ONCOLOGY PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-401-8726
Mailing Address - Street 1:1650 W ROSEDALE ST
Mailing Address - Street 2:STE 300
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-7400
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1650 W ROSEDALE ST
Practice Address - Street 2:STE 300
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-7400
Practice Address - Country:US
Practice Address - Phone:817-338-9291
Practice Address - Fax:817-335-2817
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-22
Last Update Date:2010-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX197152501Medicaid
TX00Z370Medicare PIN