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General NPI Number Information
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NPI Number | 1124302658
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Entity Type | Organization
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Legal Business Name | 99999999
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Dates
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Enumeration Date | 10/03/2011
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Last Update Date | 10/03/2011
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Provider Practice Location Address
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Address Line | 5203 WILD HORSE CT
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City | ARLINGTON
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State | TX
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Zip | 76017-2074
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Country | US
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Telephone | 817-793-0172
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Fax |
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Provider Business Mailing Address
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Address Line | 5203 WILD HORSE CT
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City | ARLINGTON
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State | TX
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Zip | 76017-2074
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Country | US
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Telephone | 817-793-0172
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Fax |
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Authorized Official
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Title or Position | PTA
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Name | MR. GARY WAYNE PATTERSON
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Credential | LPTA
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Telephone | 817-793-0172
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number | 2014064
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License Number State | TX
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