Healthcare Provider Details

I. General information

NPI: 1861434458
Provider Name (Legal Business Name): RAIFU F MUSTAPHA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2006
Last Update Date: 01/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 W ARKANSAS LN
ARLINGTON TX
76013-6376
US

IV. Provider business mailing address

1111 W ARKANSAS LN
ARLINGTON TX
76013-6376
US

V. Phone/Fax

Practice location:
  • Phone: 817-784-9454
  • Fax: 817-467-7055
Mailing address:
  • Phone: 817-784-9454
  • Fax: 817-467-7055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number631560
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number196491
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: