MEDICARE: TARRANT COUNTY AIDS INTERFAITH NETWORK

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	1223D0001X	Public Health Dentistry

General Provider Information

NPI Number	:	1518996289
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TARRANT COUNTY AIDS INTERFAITH NETWORK

Provider Business Mailing Address
First Line	:	801 W MAGNOLIA AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-4612
Country	:	US
Telephone Number	:	817-923-2800
Fax Number	:	817-923-2807

Provider Business Practice Location Address
First Line	:	200 W MAGNOLIA AVE
Second Line	:	SUITE 102
City	:	FORT WORTH
State	:	TX
Zip	:	76104-7644
Country	:	US
Telephone Number	:	817-665-1323
Fax Number	:	817-871-9074

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MS. DAPHNE MYLES
Credential	:
Telephone Number	:	817-923-2800

Provider Enumeration Date	:	07/03/2006
Last Update Date	:	08/22/2020

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