Healthcare Provider Details

I. General information

NPI: 1538754098
Provider Name (Legal Business Name): MR. TIMOTHY BRANCH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2021
Last Update Date: 03/06/2021
Certification Date: 03/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 S MAIN ST
FORT WORTH TX
76104-1224
US

IV. Provider business mailing address

1513 TERBET LN
FORT WORTH TX
76112-3314
US

V. Phone/Fax

Practice location:
  • Phone: 682-385-9611
  • Fax:
Mailing address:
  • Phone: 817-495-4461
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number234241
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: