MEDICARE: AMBASSADOR MEDICAL SUPPLY OF TEXAS 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	314000000X	Skilled Nursing Facility	120372	TX

General Provider Information

NPI Number	:	1760432538
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AMBASSADOR MEDICAL SUPPLY OF TEXAS INC

Provider Business Mailing Address
First Line	:	1714 TEASLEY LANE
Second Line	:
City	:	DENTON
State	:	TX
Zip	:	76205
Country	:	US
Telephone Number	:	940-220-6440
Fax Number	:	940-220-6443

Provider Business Practice Location Address
First Line	:	1003 COLUMBIA STREET
Second Line	:
City	:	STAMFORD
State	:	TX
Zip	:	79553
Country	:	US
Telephone Number	:	325-773-3671
Fax Number	:	325-773-5751

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JUSTIN FREEBOURN
Credential	:
Telephone Number	:	940-220-6440

Provider Enumeration Date	:	05/11/2006
Last Update Date	:	08/22/2020

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