MEDICARE: MR. WALTER FILMORE III

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	177F00000X	Lodging Provider

General Provider Information

NPI Number	:	1467699835
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. WALTER FILMORE III

Provider Business Mailing Address
First Line	:	PO BOX 152085
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76015-8085
Country	:	US
Telephone Number	:	817-691-8650
Fax Number	:

Provider Business Practice Location Address
First Line	:	1404 SUMMER BROOK CIR APT 228
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76011-4547
Country	:	US
Telephone Number	:	817-691-8650
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/07/2009
Last Update Date	:	03/31/2011

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