MEDICARE: MR. JOHNNY RAY SANDERS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171W00000X	Contractor

General Provider Information

NPI Number	:	1053755470
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOHNNY RAY SANDERS

Provider Business Mailing Address
First Line	:	2632 BOWLING GREEN AVE
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75216-3236
Country	:	US
Telephone Number	:	405-473-7230
Fax Number	:

Provider Business Practice Location Address
First Line	:	2632 BOWLING GREEN AVE
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75216-3236
Country	:	US
Telephone Number	:	405-473-7230
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/29/2013
Last Update Date	:	04/29/2013

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