Provider Demographics
NPI:1528283280
Name:TCG BENBROOK AL, LLC
Entity type:Organization
Organization Name:TCG BENBROOK AL, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:MCCALEB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-446-4792
Mailing Address - Street 1:1200 SUMMIT AVE
Mailing Address - Street 2:SUITE 444
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76102-4403
Mailing Address - Country:US
Mailing Address - Phone:817-446-4792
Mailing Address - Fax:817-446-0923
Practice Address - Street 1:4242 BRYANT IRVIN RD
Practice Address - Street 2:COVENANT PLACE OF BURLESON, LP
Practice Address - City:BENBROOK
Practice Address - State:TX
Practice Address - Zip Code:76109-4222
Practice Address - Country:US
Practice Address - Phone:817-763-0088
Practice Address - Fax:817-763-8841
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COVENANT GROUP OF TEXAS, LP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-16
Last Update Date:2015-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX000619310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001014575OtherCBA VENDOR NUMBER