MEDICARE: ATIVA HEALTH CENTER 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
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1659688406
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ATIVA HEALTH CENTER LLC

Provider Business Mailing Address
First Line	:	3510 E LANCASTER AVE
Second Line	:	SUITE B
City	:	FORT WORTH
State	:	TX
Zip	:	76103-2555
Country	:	US
Telephone Number	:	817-536-0219
Fax Number	:	817-536-0311

Provider Business Practice Location Address
First Line	:	3510 E LANCASTER AVE
Second Line	:	SUITE B
City	:	FORT WORTH
State	:	TX
Zip	:	76103-2555
Country	:	US
Telephone Number	:	817-536-0219
Fax Number	:	817-536-0311

Authorized Official
Title or Position	:	OWNER
Name	:	MS. YULIA POLIKHOVA
Credential	:
Telephone Number	:	817-536-0219

Provider Enumeration Date	:	08/31/2010
Last Update Date	:	08/31/2010

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