MEDICARE: PATRICE CHARLES 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	347C00000X	Private Vehicle	13098324	TX

General Provider Information

NPI Number	:	1154872513
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PATRICE CHARLES LLC

Provider Business Mailing Address
First Line	:	6509 MELWOOD ST
Second Line	:	2232
City	:	FORT WORTH
State	:	TX
Zip	:	76112-0917
Country	:	US
Telephone Number	:	817-683-8859
Fax Number	:

Provider Business Practice Location Address
First Line	:	6509 MELWOOD ST
Second Line	:	2232
City	:	FORT WORTH
State	:	TX
Zip	:	76112-0917
Country	:	US
Telephone Number	:	817-683-8859
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MRS. TARA ROBINSON
Credential	:
Telephone Number	:	817-683-8859

Provider Enumeration Date	:	10/20/2016
Last Update Date	:	10/20/2016

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Directions to “PATRICE CHARLES LLC ” Practice Location

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