MEDICARE: TIWANNA ORTIZ CERTIFIED HAIR LOSS

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	1744P3200X	Prosthetics Case Management	1105633	TX

General Provider Information

NPI Number	:	1144662479
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIWANNA ORTIZ CERTIFIED HAIR LOSS

Provider Business Mailing Address
First Line	:	9308 RHONI COURT
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76140
Country	:	US
Telephone Number	:	682-203-2218
Fax Number	:

Provider Business Practice Location Address
First Line	:	9308 RHONI COURT
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76140
Country	:	US
Telephone Number	:	682-203-2218
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/29/2013
Last Update Date	:	07/29/2013

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