MEDICARE: REALITY FOOT CARE 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	261Q00000X	Clinic/Center	CPED1950	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1447427562
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REALITY FOOT CARE LLC

Provider Business Mailing Address
First Line	:	2921 LACKLAND RD
Second Line	:	SUITE 101
City	:	FORT WORTH
State	:	TX
Zip	:	76116-4173
Country	:	US
Telephone Number	:	817-377-3668
Fax Number	:	817-377-2646

Provider Business Practice Location Address
First Line	:	2921 LACKLAND RD
Second Line	:	SUITE 101
City	:	FORT WORTH
State	:	TX
Zip	:	76116-4173
Country	:	US
Telephone Number	:	817-377-3668
Fax Number	:	817-377-2646

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. TERESA ANN BLACK
Credential	:	C PED
Telephone Number	:	817-377-3668

Provider Enumeration Date	:	05/08/2008
Last Update Date	:	11/15/2011

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Directions to “REALITY FOOT CARE LLC ” Practice Location

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