MEDICARE: EBOTAGBORNDANG MBI

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	305R00000X	Preferred Provider Organization		TX

General Provider Information

NPI Number	:	1629254925
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EBOTAGBORNDANG MBI

Provider Business Mailing Address
First Line	:	3951 KIRBY DR
Second Line	:	532
City	:	FORT WORTH
State	:	TX
Zip	:	76155-3925
Country	:	US
Telephone Number	:	713-202-9177
Fax Number	:	817-684-3829

Provider Business Practice Location Address
First Line	:	3951 KIRBY DR
Second Line	:	532
City	:	FORT WORTH
State	:	TX
Zip	:	76155-3925
Country	:	US
Telephone Number	:	713-202-9177
Fax Number	:	817-684-3829

Authorized Official
Title or Position	:	DIRECTOR
Name	:	EBOTAGBORNDANG MBI
Credential	:
Telephone Number	:	713-202-9177

Provider Enumeration Date	:	01/16/2008
Last Update Date	:	01/07/2009

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