MEDICARE: MEDI- ELITE, PC

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	311ZA0620X	Adult Care Home Facility	AP117597	TX
2	314000000X	Skilled Nursing Facility	AP117597	TX
3	363L00000X	Nurse Practitioner	AP117597	TX
4	363LA2200X	Adult Health Nurse Practitioner	AP117597	TX
5	363LC1500X	Community Health Nurse Practitioner	AP117597	TX
6	363LP2300X	Primary Care Nurse Practitioner	AP117597	TX
7	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1528330792
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDI- ELITE, PC

Provider Business Mailing Address
First Line	:	4621 S COOPER ST STE 131-717
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76017-5866
Country	:	US
Telephone Number	:	214-277-2243
Fax Number	:	214-231-2926

Provider Business Practice Location Address
First Line	:	2721 CENTRAL DR
Second Line	:
City	:	BEDFORD
State	:	TX
Zip	:	76021-4810
Country	:	US
Telephone Number	:	682-703-8881
Fax Number	:	706-203-3259

Authorized Official
Title or Position	:	CEO
Name	:	DR. MAHALIA L JACKSON-BUTLER
Credential	:	DNP, APRN
Telephone Number	:	214-277-2243

Provider Enumeration Date	:	02/03/2012
Last Update Date	:	11/24/2024

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