MEDICARE: MISS MIRANDA ELISE COLE

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	247200000X	Other Technician

General Provider Information

NPI Number	:	1245766146
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS MIRANDA ELISE COLE

Provider Business Mailing Address
First Line	:	1717 FAIRMOUNT AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76110-1324
Country	:	US
Telephone Number	:	940-799-7922
Fax Number	:

Provider Business Practice Location Address
First Line	:	1717 FAIRMOUNT AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76110-1324
Country	:	US
Telephone Number	:	940-799-7922
Fax Number	:

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

Provider Enumeration Date	:	05/11/2017
Last Update Date	:	05/11/2017

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