MEDICARE: ANGELA C BALEZTENA LAT, ATC

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	174400000X	Specialist		TX

General Provider Information

NPI Number	:	1629515937
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANGELA C BALEZTENA LAT, ATC

Provider Business Mailing Address
First Line	:	4141 S HULEN ST
Second Line	:	#1135
City	:	FORT WORTH
State	:	TX
Zip	:	76109-4970
Country	:	US
Telephone Number	:	720-236-2936
Fax Number	:

Provider Business Practice Location Address
First Line	:	4141 S HULEN ST
Second Line	:	#1135
City	:	FORT WORTH
State	:	TX
Zip	:	76109-4970
Country	:	US
Telephone Number	:	720-236-2936
Fax Number	:

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

Provider Enumeration Date	:	01/24/2017
Last Update Date	:	01/24/2017

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