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General NPI Number Information
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NPI Number | 1376787572
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Entity Type | Organization
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Legal Business Name | TEXAS REPRODUCTIVE CENTER LLC
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Dates
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Enumeration Date | 05/01/2009
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Last Update Date | 03/30/2010
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Provider Practice Location Address
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Address Line | 1800 MISTLETOE BOULELVARD SUITE 200
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City | FORT WORTH
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State | TX
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Zip | 76104
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Country | US
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Telephone | 817-546-7442
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Fax | 817-570-0411
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Provider Business Mailing Address
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Address Line | 1800 MISTLETOE BOULELVARD SUITE 200
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City | FORT WORTH
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State | TX
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Zip | 76104
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Country | US
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Telephone | 817-546-7442
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Fax | 817-570-0411
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Authorized Official
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Title or Position | BUSINESS MANAGER
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Name | M LEESA SALAMONE
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Credential |
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Telephone | 817-546-7442
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA0006X
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Taxonomy Name | Ambulatory Fertility Facility
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License Number | 45D1107754
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License Number State | TX
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