Healthcare Provider Details

I. General information

NPI: 1104738095
Provider Name (Legal Business Name): ANTREVIA C PURVIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2026
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1958 SWORD FISH DR
MANSFIELD TX
76063-8527
US

IV. Provider business mailing address

1301 E DEBBIE LN STE 102
MANSFIELD TX
76063-3376
US

V. Phone/Fax

Practice location:
  • Phone: 817-405-9570
  • Fax:
Mailing address:
  • Phone: 817-405-9570
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225000000X
TaxonomyOrthotic Fitter
License Number
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: