Healthcare Provider Details

I. General information

NPI: 1881015063
Provider Name (Legal Business Name): MODENA RUVALCABA CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2013
Last Update Date: 11/18/2020
Certification Date: 11/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 S MAIN ST FL 2
FORT WORTH TX
76104-4917
US

IV. Provider business mailing address

3501 N MACARTHUR BLVD SUITE 500
IRVING TX
75062-3651
US

V. Phone/Fax

Practice location:
  • Phone: 817-702-3000
  • Fax:
Mailing address:
  • Phone: 972-256-3700
  • Fax: 866-630-6348

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number751014
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: