MEDICARE: FYATT HEALTHCARE

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	261QH0100X	Health Service Clinic/Center	798898	TX

General Provider Information

NPI Number	:	1093050940
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FYATT HEALTHCARE

Provider Business Mailing Address
First Line	:	1608 WINDSONG TRL
Second Line	:	615
City	:	FORT WORTH
State	:	TX
Zip	:	76120-4223
Country	:	US
Telephone Number	:	267-872-9756
Fax Number	:

Provider Business Practice Location Address
First Line	:	1608 WINDSONG TRL
Second Line	:	615
City	:	FORT WORTH
State	:	TX
Zip	:	76120-4223
Country	:	US
Telephone Number	:	267-872-9756
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. OLUWAYEMISI AGBOOLA
Credential	:	FNP
Telephone Number	:	267-872-9756

Provider Enumeration Date	:	12/04/2012
Last Update Date	:	12/04/2012

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