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General NPI Number Information
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NPI Number | 1053644112
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Entity Type | Organization
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Legal Business Name | BETTY A JETAWO
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Dates
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Enumeration Date | 09/08/2009
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Last Update Date | 06/22/2011
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Provider Practice Location Address
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Address Line | 4402 BROADWAY BLVD SUITE 2
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City | GARLAND
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State | TX
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Zip | 75043-8263
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Country | US
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Telephone | 214-641-8494
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 494462
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City | GARLAND
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State | TX
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Zip | 75049-4462
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | BETTY JETAWO
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Credential |
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Telephone | 214-641-8494
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number |
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License Number State |
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