MEDICARE: INNOVATIVE HOUSECALLS LLC

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	363LF0000X	Family Nurse Practitioner	585319	TX
2	363LF0000X	Family Nurse Practitioner	589114	TX

General Provider Information

NPI Number	:	1407188667
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INNOVATIVE HOUSECALLS LLC

Provider Business Mailing Address
First Line	:	6080 S HULEN ST
Second Line	:	#360 PMB299
City	:	FORT WORTH
State	:	TX
Zip	:	76132-2622
Country	:	US
Telephone Number	:	817-908-1218
Fax Number	:	866-612-5090

Provider Business Practice Location Address
First Line	:	6080 S HULEN ST
Second Line	:	#360 PMB299
City	:	FORT WORTH
State	:	TX
Zip	:	76132-2622
Country	:	US
Telephone Number	:	817-908-1218
Fax Number	:	866-612-5090

Authorized Official
Title or Position	:	OWNER
Name	:	DEBORAH G RICE
Credential	:	NP
Telephone Number	:	817-908-1218

Provider Enumeration Date	:	02/12/2010
Last Update Date	:	02/12/2010

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