MEDICARE: DFW MEDICAL HOME PLLC

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	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1124441423
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DFW MEDICAL HOME PLLC

Provider Business Mailing Address
First Line	:	2925 SKYWAY CIR N
Second Line	:
City	:	IRVING
State	:	TX
Zip	:	75038-3510
Country	:	US
Telephone Number	:	972-675-7313
Fax Number	:	972-675-7310

Provider Business Practice Location Address
First Line	:	2925 SKYWAY CIR N
Second Line	:
City	:	IRVING
State	:	TX
Zip	:	75038-3510
Country	:	US
Telephone Number	:	972-675-7313
Fax Number	:	972-675-7310

Authorized Official
Title or Position	:	OWNER
Name	:	DR. SUMANA KETHA
Credential	:	MD
Telephone Number	:	972-639-5838

Provider Enumeration Date	:	01/23/2014
Last Update Date	:	02/04/2020

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Directions to “DFW MEDICAL HOME PLLC ” Practice Location

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