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General NPI Number Information
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NPI Number | 1356520134
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Entity Type | Organization
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Legal Business Name | FORT WORTH FAMILY PRACTICE ASSOCIATED
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Dates
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Enumeration Date | 10/30/2007
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Last Update Date | 11/11/2009
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Provider Practice Location Address
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Address Line | 8030 CAMP BOWIE W
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City | FORT WORTH
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State | TX
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Zip | 76116-6313
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Country | US
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Telephone | 817-244-4620
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Fax |
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Provider Business Mailing Address
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Address Line | 8030 CAMP BOWIE W
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City | FORT WORTH
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State | TX
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Zip | 76116-6313
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Country | US
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Telephone | 817-244-4620
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Fax | 817-560-7159
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | SANDRA ELLIS
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Credential |
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Telephone | 817-244-4620
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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 |
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License Number State | TX
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