MEDICARE: TREBLE CLEF TECHNOLOGIES

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	171000000X	Military Health Care Provider	541611	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	51PK6	OTHER	TX	CAGE CODE FOR WAWF

General Provider Information

NPI Number	:	1639518616
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TREBLE CLEF TECHNOLOGIES

Provider Business Mailing Address
First Line	:	3233 TOMAHAWK ST
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79936-2315
Country	:	US
Telephone Number	:	915-490-3697
Fax Number	:

Provider Business Practice Location Address
First Line	:	3233 TOMAHAWK ST
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79936-2315
Country	:	US
Telephone Number	:	915-490-3697
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MR. LESLIE ROBERT BURK
Credential	:
Telephone Number	:	915-490-3697

Provider Enumeration Date	:	06/23/2013
Last Update Date	:	06/23/2013

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