MEDICARE: MR. BERNARD MADISON HORNSBY JR.

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	172V00000X	Community Health Worker

General Provider Information

NPI Number	:	1083999668
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BERNARD MADISON HORNSBY JR.

Provider Business Mailing Address
First Line	:	1208 YUKON DR
Second Line	:
City	:	GLENN HEIGHTS
State	:	TX
Zip	:	75154-8827
Country	:	US
Telephone Number	:	469-658-2641
Fax Number	:

Provider Business Practice Location Address
First Line	:	1208 YUKON DR
Second Line	:
City	:	GLENN HEIGHTS
State	:	TX
Zip	:	75154-8827
Country	:	US
Telephone Number	:	469-658-2641
Fax Number	:

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

Provider Enumeration Date	:	10/14/2011
Last Update Date	:	10/14/2011

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