=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376896845
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AGAPE INTERNAL MEDICINE, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/22/2012
-----------------------------------------------------
Last Update Date | 06/02/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6080 S HULEN ST STE 360 PMB 229
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76132-2622
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-426-2932
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6080 S HULEN ST STE 360 PMB 229
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76132-2622
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-426-2932
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | DR. JOHN DARAMOLA
-----------------------------------------------------
Credential | M.D
-----------------------------------------------------
Telephone | 864-426-2932
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | N4369
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------