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General NPI Number Information
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NPI Number | 1447427562
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Entity Type | Organization
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Legal Business Name | REALITY FOOT CARE LLC
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Dates
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Enumeration Date | 05/08/2008
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Last Update Date | 11/15/2011
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Provider Practice Location Address
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Address Line | 2921 LACKLAND RD SUITE 101
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City | FORT WORTH
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State | TX
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Zip | 76116-4173
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Country | US
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Telephone | 817-377-3668
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Fax | 817-377-2646
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Provider Business Mailing Address
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Address Line | 2921 LACKLAND RD SUITE 101
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City | FORT WORTH
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State | TX
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Zip | 76116-4173
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Country | US
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Telephone | 817-377-3668
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Fax | 817-377-2646
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Authorized Official
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Title or Position | OWNER
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Name | MRS. TERESA ANN BLACK
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Credential | C PED
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Telephone | 817-377-3668
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | CPED1950
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License Number State | TX
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