MEDICARE: HOBERT SOUL FOOD CANTEEN

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	343900000X	Non-emergency Medical Transport (VAN)

General Provider Information

NPI Number	:	1316327869
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOBERT SOUL FOOD CANTEEN

Provider Business Mailing Address
First Line	:	PO BOX 163127
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76161-3127
Country	:	US
Telephone Number	:	817-919-5050
Fax Number	:	817-549-7396

Provider Business Practice Location Address
First Line	:	4023 E BERRY ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76105-4955
Country	:	US
Telephone Number	:	817-919-5050
Fax Number	:	817-549-7396

Authorized Official
Title or Position	:	OWNER
Name	:	MISS N LUCILLE GILKEY
Credential	:
Telephone Number	:	817-919-5050

Provider Enumeration Date	:	05/30/2015
Last Update Date	:	05/30/2015

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