MEDICARE: NTKC MANAGEMENT, LLC

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	207RN0300X	Nephrology Physician

General Provider Information

NPI Number	:	1457543902
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NTKC MANAGEMENT, LLC

Provider Business Mailing Address
First Line	:	3030 MATLOCK RD
Second Line	:	SUITE 205
City	:	ARLINGTON
State	:	TX
Zip	:	76015-2935
Country	:	US
Telephone Number	:	817-375-0610
Fax Number	:	817-375-0640

Provider Business Practice Location Address
First Line	:	1049 CLIFTON ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76107-2628
Country	:	US
Telephone Number	:	817-870-9941
Fax Number	:	817-870-0044

Authorized Official
Title or Position	:	CHIEF OPERATING OFFICER
Name	:	MR. DAN BACCUS
Credential	:
Telephone Number	:	817-375-0610

Provider Enumeration Date	:	08/17/2007
Last Update Date	:	08/17/2007

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