MEDICARE: YOUR CLINIC

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	261QP2300X	Primary Care Clinic/Center	532229	TX

General Provider Information

NPI Number	:	1386963965
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	YOUR CLINIC

Provider Business Mailing Address
First Line	:	1141 KINWEST PKWY
Second Line	:	SUITE 100
City	:	IRVING
State	:	TX
Zip	:	75063-3511
Country	:	US
Telephone Number	:	214-239-2222
Fax Number	:	214-239-2223

Provider Business Practice Location Address
First Line	:	1141 KINWEST PKWY
Second Line	:	SUITE 100
City	:	IRVING
State	:	TX
Zip	:	75063-3511
Country	:	US
Telephone Number	:	214-239-2222
Fax Number	:	214-239-2223

Authorized Official
Title or Position	:	FNP
Name	:	MRS. MILADYS A FRIESEN
Credential	:	FNP-BC
Telephone Number	:	214-239-2222

Provider Enumeration Date	:	05/22/2010
Last Update Date	:	05/22/2010

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Directions to “YOUR CLINIC ” Practice Location

Language	Start Address	Practice Location

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