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General NPI Number Information
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NPI Number | 1063895985
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Entity Type | Organization
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Legal Business Name | LOW TESTOSTERONE MEN'S CLINIC FW, LLC
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Dates
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Enumeration Date | 07/09/2015
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Last Update Date | 06/16/2020
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Provider Practice Location Address
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Address Line | 6115 CAMP BOWIE BLVD STE 140
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City | FORT WORTH
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State | TX
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Zip | 76116-5500
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Country | US
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Telephone | 817-416-5698
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Fax |
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Provider Business Mailing Address
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Address Line | 6115 CAMP BOWIE BLVD SUITE 140
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City | FORT WORTH
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State | TX
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Zip | 76116-5512
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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 | MANAGING MEMBER
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Name | MS. IVONNE HERLINDA BRAXTON
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Credential | MS,FNP-BC
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Telephone | 817-416-5698
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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