MEDICARE: MR. SCOTT PETTIS

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	332B00000X	Durable Medical Equipment & Medical Supplies
2	332BC3200X	Customized Equipment (DME)	ATP 60119	TX

General Provider Information

NPI Number	:	1174989982
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. SCOTT PETTIS

Provider Business Mailing Address
First Line	:	5324 DAVIS BLVD
Second Line	:
City	:	NORTH RICHLAND HILLS
State	:	TX
Zip	:	76180-6824
Country	:	US
Telephone Number	:	817-282-5273
Fax Number	:

Provider Business Practice Location Address
First Line	:	5324 DAVIS BLVD
Second Line	:
City	:	NORTH RICHLAND HILLS
State	:	TX
Zip	:	76180-6824
Country	:	US
Telephone Number	:	817-282-5273
Fax Number	:

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

Provider Enumeration Date	:	01/08/2016
Last Update Date	:	01/08/2016

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