Healthcare Provider Details

I. General information

NPI: 1366675761
Provider Name (Legal Business Name): LIBERTY B WETHINGTON CP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LIBERTY B RUSSELL

II. Dates (important events)

Enumeration Date: 09/01/2009
Last Update Date: 05/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 W MAGNOLIA AVE
FORT WORTH TX
76104-4250
US

IV. Provider business mailing address

1401 W MAGNOLIA AVE
FORT WORTH TX
76104-4250
US

V. Phone/Fax

Practice location:
  • Phone: 817-923-2101
  • Fax:
Mailing address:
  • Phone: 817-923-2101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number1215
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: