Provider Demographics
NPI:1992976351
Name:MSPF-IV GRAPEVINE OE, LP
Entity type:Organization
Organization Name:MSPF-IV GRAPEVINE OE, LP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:RONCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-651-4050
Mailing Address - Street 1:3811 TURTLE CREEK BLVD
Mailing Address - Street 2:SUITE #1850
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75219-4402
Mailing Address - Country:US
Mailing Address - Phone:214-651-4050
Mailing Address - Fax:214-651-4001
Practice Address - Street 1:1005 IRA E WOODS AVE
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-4018
Practice Address - Country:US
Practice Address - Phone:817-796-4621
Practice Address - Fax:817-796-4629
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-13
Last Update Date:2008-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX117706314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX5471OtherMEDICAID VENDOR
TX676104Medicare Oscar/Certification