MEDICARE: AGAPE INTERNAL MEDICINE, PC

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	174400000X	Specialist	N4369	TX

General Provider Information

NPI Number	:	1376896845
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AGAPE INTERNAL MEDICINE, PC

Provider Business Mailing Address
First Line	:	6080 S HULEN ST
Second Line	:	STE 360 PMB 229
City	:	FORT WORTH
State	:	TX
Zip	:	76132-2622
Country	:	US
Telephone Number	:	864-426-2932
Fax Number	:

Provider Business Practice Location Address
First Line	:	6080 S HULEN ST
Second Line	:	STE 360 PMB 229
City	:	FORT WORTH
State	:	TX
Zip	:	76132-2622
Country	:	US
Telephone Number	:	864-426-2932
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	DR. JOHN DARAMOLA
Credential	:	M.D
Telephone Number	:	864-426-2932

Provider Enumeration Date	:	10/22/2012
Last Update Date	:	06/02/2013

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