MEDICARE: LACI BIRDEN

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	225100000X	Physical Therapist	1162968	TX

General Provider Information

NPI Number	:	1861815920
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LACI BIRDEN

Provider Business Mailing Address
First Line	:	2504 ENSENADA LN
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76108-4992
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2504 ENSENADA LN
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76108-4992
Country	:	US
Telephone Number	:	817-598-0162
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/27/2014
Last Update Date	:	01/27/2014

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Directions to “ LACI BIRDEN ” Practice Location

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