MEDICARE: FOOT SOLUTIONS OF FORT WORTH, INC.

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	335E00000X	Prosthetic/Orthotic Supplier

General Provider Information

NPI Number	:	1639440126
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FOOT SOLUTIONS OF FORT WORTH, INC.

Provider Business Mailing Address
First Line	:	4825 OVERTON RIDGE BLVD
Second Line	:	SUITE 316
City	:	FORT WORTH
State	:	TX
Zip	:	76132-1423
Country	:	US
Telephone Number	:	817-423-3668
Fax Number	:	817-423-3671

Provider Business Practice Location Address
First Line	:	4825 OVERTON RIDGE BLVD
Second Line	:	SUITE 316
City	:	FORT WORTH
State	:	TX
Zip	:	76132-1423
Country	:	US
Telephone Number	:	817-423-3668
Fax Number	:	817-423-3671

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MARIE-JOSE V SMITH
Credential	:
Telephone Number	:	817-423-3668

Provider Enumeration Date	:	01/16/2012
Last Update Date	:	01/16/2012

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