MEDICARE: TSA CLINIC PLLC

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	207L00000X	Anesthesiology Physician

General Provider Information

NPI Number	:	1407207392
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TSA CLINIC PLLC

Provider Business Mailing Address
First Line	:	3160 N TARRANT PKWY STE 404
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76177-8614
Country	:	US
Telephone Number	:	972-707-0005
Fax Number	:

Provider Business Practice Location Address
First Line	:	3160 N TARRANT PKWY STE 404
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76177-8614
Country	:	US
Telephone Number	:	972-707-0005
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	MARK C VALENTE
Credential	:	D.O.
Telephone Number	:	972-707-0005

Provider Enumeration Date	:	06/22/2016
Last Update Date	:	07/25/2016

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