MEDICARE: HEBRON FAMILY LIFE CENTER

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	1041C0700X	Clinical Social Worker	27423	TX

General Provider Information

NPI Number	:	1073767331
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEBRON FAMILY LIFE CENTER

Provider Business Mailing Address
First Line	:	2335 56TH ST
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75241-1437
Country	:	US
Telephone Number	:	214-374-7505
Fax Number	:

Provider Business Practice Location Address
First Line	:	2335 56TH ST
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75241-1437
Country	:	US
Telephone Number	:	214-374-7505
Fax Number	:

Authorized Official
Title or Position	:	PROGRAM ADMINISTRATOR
Name	:	MR. DAVID ROBISON
Credential	:	B.A.
Telephone Number	:	972-898-9628

Provider Enumeration Date	:	11/12/2008
Last Update Date	:	11/12/2008

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