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General NPI Number Information
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NPI Number | 1114919172
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Entity Type | Organization
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Legal Business Name | HEALTH TEXAS PROVIDER NETWORK-FAMILY PRACTICE OF NORTH TEXAS LLP
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Dates
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Enumeration Date | 08/16/2005
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Last Update Date | 02/19/2008
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Provider Practice Location Address
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Address Line | 1001 12TH AVE SUITE 130
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City | FORT WORTH
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State | TX
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Zip | 76104-3926
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Country | US
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Telephone | 817-921-6166
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Fax | 817-921-9594
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Provider Business Mailing Address
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Address Line | 8080 N CENTRAL EXPY SUITE 1650
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City | DALLAS
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State | TX
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Zip | 75206-1838
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Country | US
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Telephone | 972-860-8653
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Fax | 972-860-8679
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Authorized Official
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Title or Position | DIRECTOR
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Name | MRS. ELLEN ELIZABETH FOURTON
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Credential |
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Telephone | 972-860-8649
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 00997Y
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License Number State | TX
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