MEDICARE: BETTY A JETAWO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1053644112
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BETTY A JETAWO

Provider Business Mailing Address
First Line	:	PO BOX 494462
Second Line	:
City	:	GARLAND
State	:	TX
Zip	:	75049-4462
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4402 BROADWAY BLVD
Second Line	:	SUITE 2
City	:	GARLAND
State	:	TX
Zip	:	75043-8263
Country	:	US
Telephone Number	:	214-641-8494
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	BETTY JETAWO
Credential	:
Telephone Number	:	214-641-8494

Provider Enumeration Date	:	09/08/2009
Last Update Date	:	06/22/2011

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