MEDICARE: B J RUST 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	332B00000X	Durable Medical Equipment & Medical Supplies	DR0128	TX

General Provider Information

NPI Number	:	1346459500
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	B J RUST JR

Provider Business Mailing Address
First Line	:	4825 CAMP BOWIE BLVD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76107-4150
Country	:	US
Telephone Number	:	817-731-4646
Fax Number	:	817-731-4646

Provider Business Practice Location Address
First Line	:	4825 CAMP BOWIE BLVD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76107-4150
Country	:	US
Telephone Number	:	817-731-4646
Fax Number	:	817-731-4646

Authorized Official
Title or Position	:	OPTICIAN
Name	:	MR. B. J. RUST JR.
Credential	:	OPTICIAN
Telephone Number	:	817-338-1121

Provider Enumeration Date	:	05/22/2007
Last Update Date	:	11/03/2008

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