Provider Demographics
NPI:1386807204
Name:CATHOLIC CHARITIES DIOCESE OF FORT WORTH INC
Entity type:Organization
Organization Name:CATHOLIC CHARITIES DIOCESE OF FORT WORTH INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT OF ADMINISTRATION
Authorized Official - Prefix:MRS
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:GAIL
Authorized Official - Last Name:QUIROZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-413-3912
Mailing Address - Street 1:2701 BURCHILL RD N
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76105-3012
Mailing Address - Country:US
Mailing Address - Phone:817-413-3912
Mailing Address - Fax:817-535-8779
Practice Address - Street 1:2701 BURCHILL RD N
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76105-3012
Practice Address - Country:US
Practice Address - Phone:817-413-3912
Practice Address - Fax:817-535-8779
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-10
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX111439903Medicaid