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General NPI Number Information
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NPI Number | 1568716595
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Entity Type | Organization
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Legal Business Name | FOUNDATION
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Dates
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Enumeration Date | 10/29/2012
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Last Update Date | 10/29/2012
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Provider Practice Location Address
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Address Line | 874 THOMAS CROSSING DR
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City | BURLESON
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State | TX
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Zip | 76028-3206
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Country | US
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Telephone | 682-234-9152
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Fax |
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Provider Business Mailing Address
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Address Line | 874 THOMAS CROSSING DR
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City | BURLESON
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State | TX
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Zip | 76028-3206
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PROGRAM MANAGER
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Name | MS. TOBEY R MCCRORY
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Credential |
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Telephone | 682-234-9152
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305S00000X
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Taxonomy Name | Point of Service
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License Number |
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License Number State | TX
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