Healthcare Provider Details

I. General information

NPI: 1083999668
Provider Name (Legal Business Name): MR. BERNARD MADISON HORNSBY JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2011
Last Update Date: 10/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1208 YUKON DR
GLENN HEIGHTS TX
75154-8827
US

IV. Provider business mailing address

1208 YUKON DR
GLENN HEIGHTS TX
75154-8827
US

V. Phone/Fax

Practice location:
  • Phone: 469-658-2641
  • Fax:
Mailing address:
  • Phone: 469-658-2641
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: