=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093259293
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALLERGY RELIEF OF TEXAS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/07/2016
-----------------------------------------------------
Last Update Date | 12/07/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7200 DUTCH BRANCH RD SUITE 200
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76132-4143
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-346-7676
-----------------------------------------------------
Fax | 817-346-7779
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7200 DUTCH BRANCH RD SUITE 200
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76132-4143
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-346-7676
-----------------------------------------------------
Fax | 817-346-7779
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JAMES CAMERON THOMPSON
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 817-346-7676
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207KA0200X
-----------------------------------------------------
Taxonomy Name | Allergy Physician
-----------------------------------------------------
License Number | L2028
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------