Provider Demographics
NPI:1699708362
Name:FORT WORTH PRIMARY CARE PROVIDERS
Entity type:Organization
Organization Name:FORT WORTH PRIMARY CARE PROVIDERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIVISION VP
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:PAIGE
Authorized Official - Last Name:LAWRENCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:682-432-0459
Mailing Address - Street 1:2501 PARKVIEW DR
Mailing Address - Street 2:SUITE 330
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76102-5824
Mailing Address - Country:US
Mailing Address - Phone:682-432-0459
Mailing Address - Fax:682-432-0471
Practice Address - Street 1:2501 PARKVIEW DR
Practice Address - Street 2:SUITE 330
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76102-5824
Practice Address - Country:US
Practice Address - Phone:682-432-0459
Practice Address - Fax:682-432-0471
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UNITED HOSPICE SERVICES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-08
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX245713363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00W072Medicare PIN