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General NPI Number Information
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NPI Number | 1689922627
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Entity Type | Organization
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Legal Business Name | ALLIANCE HERITAGE TRACE PLLC
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Dates
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Enumeration Date | 08/23/2012
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Last Update Date | 10/10/2012
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Provider Practice Location Address
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Address Line | 4400 HERITAGE TRACE PKWY SUITE 208
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City | FORT WORTH
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State | TX
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Zip | 76244-8901
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Country | US
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Telephone | 817-741-5437
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Fax | 888-400-5412
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Provider Business Mailing Address
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Address Line | 12461 TIMBERLAND BLVD SUITE 309
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City | FORT WORTH
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State | TX
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Zip | 76244-5213
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Country | US
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Telephone | 817-741-5437
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Fax | 888-400-5412
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Authorized Official
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Title or Position | OWNER
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Name | MR. BRUCE DAVID MARTIN
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Credential | MD
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Telephone | 817-741-5437
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | L8824
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License Number State | TX
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