Healthcare Provider Details

I. General information

NPI: 1184669673
Provider Name (Legal Business Name): CLINICAL NEPHROLOGY ASSOCIATES, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2006
Last Update Date: 09/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 MISTLETOE BLVD
FORT WORTH TX
76104-4042
US

IV. Provider business mailing address

PO BOX 470787
FORT WORTH TX
76147-0787
US

V. Phone/Fax

Practice location:
  • Phone: 817-923-8050
  • Fax: 817-923-8832
Mailing address:
  • Phone: 817-923-8050
  • Fax: 817-923-8832

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JACK ORRIN GRATCH
Title or Position: CEO
Credential: DO
Phone: 817-923-8050