MEDICARE: JAKOB A DEVORE LSA

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	246ZS0410X	Surgical Technologist	142172	KS
2	246ZC0007X	Surgical Assistant	SA00729	TX

General Provider Information

NPI Number	:	1245686518
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAKOB A DEVORE LSA

Provider Business Mailing Address
First Line	:	5309 CORN FIELD DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76179-8163
Country	:	US
Telephone Number	:	214-227-2457
Fax Number	:	214-764-0880

Provider Business Practice Location Address
First Line	:	5309 CORN FIELD DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76179-8163
Country	:	US
Telephone Number	:	214-227-2457
Fax Number	:	214-764-0880

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

Provider Enumeration Date	:	05/05/2016
Last Update Date	:	09/10/2020

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