MEDICARE: DEHAVEN DIAGNOSTICS, LLC

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	208100000X	Physical Medicine & Rehabilitation Physician

General Provider Information

NPI Number	:	1124369459
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DEHAVEN DIAGNOSTICS, LLC

Provider Business Mailing Address
First Line	:	6116 OAKBEND TRL
Second Line	:	SUITE 106
City	:	FORT WORTH
State	:	TX
Zip	:	76132-3925
Country	:	US
Telephone Number	:	817-984-6210
Fax Number	:	817-984-6216

Provider Business Practice Location Address
First Line	:	6116 OAKBEND TRL
Second Line	:	SUITE 106
City	:	FORT WORTH
State	:	TX
Zip	:	76132-3925
Country	:	US
Telephone Number	:	817-984-6210
Fax Number	:	817-984-6216

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	DR. ROBERT JUDSON BALCH III
Credential	:	D.O.
Telephone Number	:	817-984-6210

Provider Enumeration Date	:	03/12/2013
Last Update Date	:	03/12/2013

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