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NPI Code Detail

MEDICARE: SP 1 MEDICAL HOLDING LLC

MEDICARE: SP 1 MEDICAL HOLDING 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
1204R00000XElectrodiagnostic Medicine Physician

General Provider Information

NPI Number : 1538711338
Entity Type Code : Organization
Provider Name (Legal Business Name) : SP 1 MEDICAL HOLDING LLC
Provider Business Mailing Address
First Line : 111 BOLAND ST STE 211
Second Line :
City : FORT WORTH
State : TX
Zip : 76107-1265
Country : US
Telephone Number : 817-529-8488
Fax Number : 903-328-6568
Provider Business Practice Location Address
First Line : 111 BOLAND ST STE 211
Second Line :
City : FORT WORTH
State : TX
Zip : 76107-1265
Country : US
Telephone Number : 817-529-8488
Fax Number : 903-328-6568
Authorized Official
Title or Position : BILLING MANAGER
Name : GINA SULLIVAN
Credential :
Telephone Number : 817-529-8488
Provider Enumeration Date : 07/11/2019
Last Update Date : 07/11/2019

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Directions to “SP 1 MEDICAL HOLDING LLC ” Practice Location

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