MEDICARE: SOUTHERN HORIZON HEALTHCARE, PLLC

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	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1649691429
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN HORIZON HEALTHCARE, PLLC

Provider Business Mailing Address
First Line	:	2014 JUSTIN RD
Second Line	:	SUITE 104
City	:	HIGHLAND VILLAGE
State	:	TX
Zip	:	75077-7161
Country	:	US
Telephone Number	:	469-645-0200
Fax Number	:	469-637-0000

Provider Business Practice Location Address
First Line	:	2014 JUSTIN RD
Second Line	:	SUITE 104
City	:	HIGHLAND VILLAGE
State	:	TX
Zip	:	75077-7161
Country	:	US
Telephone Number	:	469-645-0200
Fax Number	:	469-637-0000

Authorized Official
Title or Position	:	CO-OWNER
Name	:	DR. JENNIFER M BONTREGER
Credential	:	D.O.
Telephone Number	:	469-645-0200

Provider Enumeration Date	:	12/23/2013
Last Update Date	:	02/01/2014

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