MEDICARE: AIDS HEALTHCARE FOUNDATION TEXAS INC

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	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1104190115
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AIDS HEALTHCARE FOUNDATION TEXAS INC

Provider Business Mailing Address
First Line	:	6255 W SUNSET BLVD FL 21
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90028-7422
Country	:	US
Telephone Number	:	323-860-5200
Fax Number	:	833-241-7615

Provider Business Practice Location Address
First Line	:	400 N BEACH ST
Second Line	:	SUITE 104
City	:	FORT WORTH
State	:	TX
Zip	:	76111-7010
Country	:	US
Telephone Number	:	817-831-1750
Fax Number	:	817-831-1753

Authorized Official
Title or Position	:	CHIEF, MANAGED CARE
Name	:	DONNA STIDHAM
Credential	:
Telephone Number	:	323-436-5025

Provider Enumeration Date	:	03/08/2012
Last Update Date	:	09/11/2019

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